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BACKGROUND: Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. OBJECTIVES: To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty. DESIGN: Qualitative study using individual in-depth interviews. PARTICIPANTS: Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital. MEASUREMENTS: Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. RESULTS: Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. CONCLUSIONS: Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.
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Médicos , Estudiantes de Medicina , Actitud del Personal de Salud , Niño , Humanos , Investigación Cualitativa , IncertidumbreRESUMEN
Numerous and substantial challenges exist in the provision of safe, cost-effective, and efficient health care. The prevalence and consequences of diagnostic error, one of these challenges, have been established by the literature; however, these errors persist, and the pace of improvement has been slow. One potential reason for the lack of needed progress is that addressing delayed and wrong diagnoses will require contributions from 2 currently distinct worlds: clinical reasoning and diagnostic error. In this Invited Commentary, the authors argue for merging the diagnostic error and clinical reasoning fields as the perspectives, frameworks, and methodologies of these 2 fields could be leveraged to yield a more aligned approach to understanding and subsequently to mitigating diagnostic error. The authors focus on the problem of diagnostic labeling (a categorization task where one has to choose the correct label or diagnosis). The authors elaborate on why this alignment could help guide health care improvement efforts, using the vexing problem of context specificity that leads to unwanted variance in health care as an example.
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Toma de Decisiones Clínicas , Errores Diagnósticos , Mejoramiento de la Calidad , Diagnóstico Tardío , HumanosRESUMEN
BACKGROUND: Four-factor PCC is the recommended standard of care for acute warfarin reversal but optimal dosing is unknown. We aim to show that a low-dose strategy is often adequate and may reduce the risk of thromboembolic events when compared to manufacturer-recommended dosing. METHODS: A weight-based dosing strategy of 15-25 units/kg was established as the institutional standard of care in May 2015. This retrospective, before-and-after cohort analysis included patients receiving 4F-PCC according to a manufacturer-recommended (n = 122) or a low-dose (n = 83) strategy. The primary efficacy outcome was a combination of INR reversal on first check and hemostatic efficacy at 24 h. RESULTS: Demographics, indications for warfarin, and presenting INR values were similar between the two groups. Patients in the manufacturer-recommended dose group received significantly more 4F-PCC than the low dose group (2110 units vs. 1530 units). More patients in the manufacturer-recommended dose group achieved the primary endpoint (75.4% vs. 61.4%), with more patients achieving the target INR on recheck in the manufacturer-recommended dose group (95.9% vs. 84.3%) and no difference in hemostatic efficacy between groups (79.5% vs. 74.7%). There was no difference in thromboembolic events at 72 h (4.1% vs. 1.2%) or at 30 days (8.2% vs. 4.8%). Significantly more patients in the manufacturer-recommended dose group died or were transferred to hospice care during hospitalization (21.3% vs. 9.6%). CONCLUSION: Utilization of a low-dose 4F-PCC strategy resulted in fewer patients achieving target INR reversal, but no difference in hemostatic efficacy, thromboembolic events, or survival.
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Anticoagulantes , Factores de Coagulación Sanguínea/administración & dosificación , Hemorragia/tratamiento farmacológico , Hemostasis/efectos de los fármacos , Antagonistas de Heparina/administración & dosificación , Warfarina/antagonistas & inhibidores , Anciano , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Factores de Coagulación Sanguínea/efectos adversos , Peso Corporal , Cálculo de Dosificación de Drogas , Monitoreo de Drogas/métodos , Femenino , Hemorragia/inducido químicamente , Hemorragia/diagnóstico , Antagonistas de Heparina/efectos adversos , Humanos , Relación Normalizada Internacional , Masculino , Modelos Biológicos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Warfarina/administración & dosificación , Warfarina/efectos adversosRESUMEN
BACKGROUND: Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error). METHODS: Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures. RESULTS: Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070). CONCLUSION: This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.
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Competencia Clínica/estadística & datos numéricos , Errores Diagnósticos/estadística & datos numéricos , Educación Médica/métodos , Evaluación Educacional , Médicos , Estudiantes de Medicina , Adulto , Anciano , Conducta de Elección , Cognición , Evaluación Educacional/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Solución de Problemas , Estudios ProspectivosRESUMEN
Background Excellence in clinical reasoning is one of the most important outcomes of medical education programs, but assessing learners' reasoning to inform corrective feedback is challenging and unstandardized. Methods The Society to Improve Diagnosis in Medicine formed a multi-specialty team of medical educators to develop the Assessment of Reasoning Tool (ART). This paper describes the tool development process. The tool was designed to facilitate clinical teachers' assessment of learners' oral presentation for competence in clinical reasoning and facilitate formative feedback. Reasoning frameworks (e.g. script theory), contemporary practice goals (e.g. high-value care [HVC]) and proposed error reduction strategies (e.g. metacognition) were used to guide the development of the tool. Results The ART is a behaviorally anchored, three-point scale assessing five domains of reasoning: (1) hypothesis-directed data gathering, (2) articulation of a problem representation, (3) formulation of a prioritized differential diagnosis, (4) diagnostic testing aligned with HVC principles and (5) metacognition. Instructional videos were created for faculty development for each domain, guided by principles of multimedia learning. Conclusions The ART is a theory-informed assessment tool that allows teachers to assess clinical reasoning and structure feedback conversations.
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Toma de Decisiones Clínicas , Toma de Decisiones , Errores Diagnósticos/prevención & control , Educación Médica/métodos , Evaluación Educacional/métodos , Docentes Médicos , Estudiantes de Medicina , Competencia Clínica , Cognición , Diagnóstico Diferencial , Retroalimentación , Humanos , Aprendizaje , Calidad de la Atención de Salud , Sociedades , Desarrollo de Personal , EnseñanzaRESUMEN
BACKGROUND: Diagnostic error is a major problem in health care, yet there are few medical school curricula focused on improving the diagnostic process and decreasing diagnostic errors. Effective strategies to teach medical students about diagnostic error and diagnostic safety have not been established. METHODS: We designed, implemented and evaluated a virtual patient module featuring two linked cases involving diagnostic errors. Learning objectives developed by a consensus process among medical educators in the Society to Improve Diagnosis in Medicine (SIDM) were utilized. The module was piloted with internal medicine clerkship students at three institutions and with clerkship faculty members recruited from listservs. Participants completed surveys on their experience using the case and a qualitative analysis was performed. RESULTS: Thirty-five medical students and 25 faculty members completed the survey. Most students found the module to be relevant and instructive. Faculty also found the module valuable for students but identified insufficient curricular time as a barrier to implementation. CONCLUSIONS: Medical students and faculty found a prototype virtual patient module about the diagnostic process and diagnostic error to be educational.
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Curriculum , Errores Diagnósticos , Educación Médica/métodos , Medicina Interna/educación , Aprendizaje Basado en Problemas , Actitud , Prácticas Clínicas , Docentes Médicos , Humanos , Proyectos Piloto , Investigación Cualitativa , Sociedades , Estudiantes de Medicina , Encuestas y Cuestionarios , EnseñanzaRESUMEN
Background Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described. Methods We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance. Results Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases. Conclusions The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.
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Competencia Clínica , Toma de Decisiones Clínicas , Cognición , Computadores , Errores Diagnósticos , Médicos , Solución de Problemas , Sesgo , Comprensión , Simulación por Computador , Errores Diagnósticos/prevención & control , Humanos , Proyectos PilotoRESUMEN
PURPOSE: As attention has shifted to learners as significant partners in feedback interactions, it is important to explore what feedback-seeking behaviors medical students use and how the faculty-student relationship affects feedback-seeking behaviors. METHOD: This qualitative study was inspired by the organizational psychology literature. Third-year medical students were interviewed at Maine Medical Center in April-May 2017 after completing a traditional block rotation clerkship or a nine-month longitudinal integrated clerkship (LIC). A constructivist grounded theory approach was used to analyze transcripts and develop themes. RESULTS: Fourteen students participated (eight LIC, six block rotation). Themes associated with why students sought feedback included goal orientations, perceived benefits and costs, and student and feedback provider characteristics. Factors influencing the way students sought feedback included busy environments, timing, and cues students were attuned to. Students described more inquiry than monitoring approaches and used various indirect and noninquiry techniques (artifice) in asking for feedback. Students did not find summative feedback as helpful as seeking feedback themselves, and they suggested training in seeking feedback would be beneficial. Faculty-student relationship dynamics included several aspects affecting feedback-seeking behaviors, and relationship differences in the LIC and block models affected feedback-seeking behaviors. CONCLUSIONS: Medical students have many motives to seek feedback and adapt their feedback-seeking behaviors to actively participate in an intricate dialogic interaction with feedback providers. Students gradually refine the art (and artifice) of obtaining the specific feedback information that meets their needs. The authors offer a prototype curriculum that may facilitate students' development of feedback-seeking skills.
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Prácticas Clínicas/métodos , Retroalimentación , Estudiantes de Medicina/psicología , Prácticas Clínicas/estadística & datos numéricos , Humanos , Relaciones Interpersonales , Maine , Investigación Cualitativa , Estudiantes de Medicina/estadística & datos numéricosRESUMEN
Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators' limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.
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Competencia Clínica/normas , Docentes Médicos/normas , Enseñanza/normas , Diagnóstico , Educación Médica , Humanos , Solución de ProblemasRESUMEN
BACKGROUND AND OBJECTIVES: In 2016, we performed a scoping review as a means of mapping what is known in the literature about feedback to medical learners. In this descriptive analysis, we explore a subset of the results to assess the contributions of predominantly North American family medicine educators to the feedback literature. METHODS: Nineteen articles extracted from our original scoping review plus six articles identified from an additional search of the journal Family Medicine are described in-depth. RESULTS: The proportion of articles involving family medicine educators identified in our scoping review is small (n=19/650, 3%) and the total remains low (25) after including additional articles (n=6) from a Family Medicine search. They encompass a broad range of feedback methods and content areas. They primarily originated in the United States (n=19) and Canada (n=3) within Family Medicine Departments (n=20) and encompass a variety of scientific and educational research methodologies. CONCLUSIONS: The contributions of predominantly North American Family Medicine educators to the literature on feedback to learners are sparse in number and employ a variety of focus areas and methodological approaches. More studies are needed to assess for areas of education research where family physicians could make valuable contributions.
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Educación Médica/métodos , Medicina Familiar y Comunitaria/educación , Retroalimentación Formativa , Humanos , Aprendizaje , América del NorteRESUMEN
PURPOSE: To conduct an integrative review and analysis of the literature on the content of feedback to learners in medical education. METHOD: Following completion of a scoping review in 2016, the authors analyzed a subset of articles published through 2015 describing the analysis of feedback exchange content in various contexts: audiotapes, clinical examination, feedback cards, multisource feedback, videotapes, and written feedback. Two reviewers extracted data from these articles and identified common themes. RESULTS: Of the 51 included articles, about half (49%) were published since 2011. Most involved medical students (43%) or residents (43%). A leniency bias was noted in many (37%), as there was frequently reluctance to provide constructive feedback. More than one-quarter (29%) indicated the feedback was low in quality (e.g., too general, limited amount, no action plans). Some (16%) indicated faculty dominated conversations, did not use feedback forms appropriately, or provided inadequate feedback, even after training. Multiple feedback tools were used, with some articles (14%) describing varying degrees of use, completion, or legibility. Some articles (14%) noted the impact of the gender of the feedback provider or learner. CONCLUSIONS: The findings reveal that the exchange of feedback is troubled by low-quality feedback, leniency bias, faculty deficient in feedback competencies, challenges with multiple feedback tools, and gender impacts. Using the tango dance form as a metaphor for this dynamic partnership, the authors recommend ways to improve feedback for teachers and learners willing to partner with each other and engage in the complexities of the feedback exchange.
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Docentes Médicos , Retroalimentación Formativa , Estudiantes de Medicina , Femenino , Humanos , Internado y Residencia , Masculino , Competencia Profesional , Factores SexualesRESUMEN
This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.
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Educación Basada en Competencias/tendencias , Educación Médica/tendencias , Comunicación Interdisciplinaria , Relaciones Interprofesionales , Actitud del Personal de Salud , Docentes Médicos , Humanos , Sociedades Médicas , Estudiantes de Medicina , Estados UnidosRESUMEN
BACKGROUND: Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. OBJECTIVE: To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: US institutional members of the Clerkship Directors in Internal Medicine (CDIM). MAIN MEASURES: Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. KEY RESULTS: The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. CONCLUSIONS: Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.
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Prácticas Clínicas , Toma de Decisiones Clínicas , Medicina Interna/educación , Ejecutivos Médicos , Facultades de Medicina , Encuestas y Cuestionarios , Prácticas Clínicas/métodos , Prácticas Clínicas/normas , Toma de Decisiones Clínicas/métodos , Estudios Transversales , Femenino , Humanos , Medicina Interna/métodos , Medicina Interna/normas , Masculino , Solución de Problemas , Facultades de Medicina/normas , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: To investigate the association of medical learner feedback with patient management and outcomes. METHODS: The authors investigated 27 articles that utilized patient data or chart reviews as a subset of a prior feedback scoping review. Data extraction was completed by two authors and all authors reviewed the descriptive data analysis. RESULTS: The studies were predominantly short-term investigations conducted in the US at academic teaching hospitals (89%) with one medical discipline (78%), most commonly internal medicine (56%). Patient-related outcomes primarily involved improved documentation (26%) and adherence to practice guidelines (19%) and were mostly measured through chart reviews (56%) or direct observation (15%). The primary method of feedback delivery involved a written format (30%). The majority of the studies showed a positive effect of feedback on the patient-oriented study outcomes (82%), although most involved a non-rigorous study design. CONCLUSIONS: Published studies focusing on the relationship between medical learner feedback and patient care are sparse. Most involve a single discipline at a single institution and are of a non-rigorous design. Measurements of improved patient outcomes are restricted to changes in management, procedures and documentation. Well-designed studies that directly link learner feedback to patient outcomes may help to support the use of feedback in teaching clinical outcomes improvement in alignment with competency-based milestones.
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BACKGROUND: Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6-1.9 are also associated with poor outcomes. METHODS: We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6-1.9) in the setting of both traumatic and spontaneous intracranial bleeding. RESULTS: A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6-1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration. CONCLUSIONS: The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6-1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.
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Anticoagulantes/efectos adversos , Factores de Coagulación Sanguínea/farmacología , Hemorragia Intracraneal Traumática/tratamiento farmacológico , Hemorragias Intracraneales/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Warfarina/efectos adversos , Anciano , Anciano de 80 o más Años , Factores de Coagulación Sanguínea/administración & dosificación , Femenino , Humanos , Relación Normalizada Internacional , Hemorragias Intracraneales/inducido químicamente , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: To conduct a scoping review of the literature on feedback for learners in medical education. METHOD: In 2015-2016, the authors searched the Ovid MEDLINE, ERIC, CINAHL, ProQuest Dissertations and Theses Global, Web of Science, and Scopus databases and seven medical education journals (via OvidSP) for articles published January 1980-December 2015. Two reviewers screened articles for eligibility with inclusion criteria. All authors extracted key data and analyzed data descriptively. RESULTS: The authors included 650 articles in the review. More than half (n = 341) were published during 2010-2015. Many centered on medical students (n = 274) or residents (n = 192); some included learners from other disciplines (n = 57). Most (n = 633) described methods used for giving feedback; some (n = 95) described opinions and recommendations regarding feedback. Few studies assessed approaches to feedback with randomized, educational trials (n = 49) or described changes in learner behavior after feedback (n = 49). Even fewer assessed the impact of feedback on patient outcomes (n = 28). CONCLUSIONS: Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.