Open Access Open Access  Restricted Access Subscription Access

Teaching and learning clinical decision-making for person-centered medicine: recommendations from a systematic review of the literature

Gareth Walters

Abstract


Rationale, aims and objectives: Clinical decision-making (CDM) has been studied from diverse perspectives, including diagnostic cognition, clinical error and probabilistic modelling of patient management under uncertainty. This paper aims to establish the current knowledge base for CDM by systematic review, in order to produce recommendations for clinicians and clinical teachers.

Method: Biomedical, social science and education databases were searched. All English-language articles concerning CDM in medical education, from peer-reviewed academic journals, were included.  Meeting abstracts were hand searched for relevance. 236 citation abstracts were kept for consideration, then themed for ease of analysis. Current thinking was reviewed and discussed, and key recommendations for teaching CDM were made for clinicians.

Results: The hypothetico-deductive cognitive method is criticised, as experts use little hypothesis testing. Clinical expertise is associated with better content-specific memory, consisting of encapsulated biomedical and clinical knowledge as goal-directed knowledge-structures (illness scripts). These are rich, accessible and activated intuitively (pattern recognition). Decision theory and Bayes’ theorem provide a mathematical rule for rationalising a hypothesis and decision analysis updates this for complex decisions. Clinicians should appreciate the nature and impact of cognitive errors on CDM and use cognitive forcing strategies to lessen them. 

Conclusion: Analytical and non-analytical (intuitive) models of CDM are not mutually exclusive and dual-process or additive models of CDM account for this.  Key recommendations for clinical teaching include development of knowledge encapsulations as individual constructs, combined learning of analytical and intuitive elements and reducing cognitive error by metacognition, forcing strategies and constructive feedback.

Full Text:

PDF

References


Tooke, J. (2008). Aspiring to excellence: findings and final recommendations of the independent inquiry into Modernising Medical Careers. London: Aldridge Press.

Medical Schools Council. The consensus statement on the role of the doctor. (http://www.medschools.ac.uk/News/Pages/Role-of-the-Doctor.aspx). London: Medical Schools Council, 2008. Accessed on 14th March 2012.

Department of Health (2008). A high quality workforce: the NHS next stage review. London: Department of Health.

General Medical Council. (2009). Tomorrows doctors. London: GMC publications.

Round, A. P. (2001). Introduction to clinical reasoning. Journal of Evaluation in Clinical Practice 7. 109-117.

Norman, G. R. (2005). Research in clinical reasoning: past history and current trends. Medical Education, 39, 418-427.

Elstein, A. S. & Schwartz, A. (2002). Clinical problem solving and diagnostic decision-making: selective review of the cognitive literature. British Medical Journal 324, 729-732.

Eva, K. W. (2004). What every teacher needs to know about clinical reasoning. Medical Education 39, 98-106.

Haig, A. & Dozier, M. (2003). BEME Guide No 3: Systematic searching for evidence in medical education - Part 1: Sources of information. Medical Teacher 25, 352-363.

Elstein, A. S., Kagan, N., Shulman, L. S., Jason, H. & Loupe, M. J. (1972). Methods and theory in the study of medical inquiry. Journal of Medical Education 47, 86-92.

Neufeld, V. R., Norman, G. R., Barrows, H. S. & Feightner, J. W. (1981). Clinical problem solving by medical students: a longitudinal and cross sectional analysis. Medical Education 15, 315-322.

Barrows, H. S., Norman, G. R., Neufeld, V. R. & Feightner, J. W. (1982). The clinical reasoning process of randomly selected physicians in general medical practice. Clinical Investigations in Medicine 5, 49-56.

Durning, S., Artino, A. R., Pangaro, L., van der Vleuten, C. P. & Schuwirth, L. (2011). Context and clinical reasoning: understanding the perspective of the expert's voice. Medical Education 45, 927-938.

Patel, V. L. & Groen, G. J. (1986). Knowledge-based solution strategies in medical reasoning. Cognitive Science 10, 91-116.

Dreyfus, S. E. & Dreyfus, H. L. (1986). Mind over machine: the power of human intuition and expertise in the era of the computer. New York: The Free Press.

Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice, pp. 10-34. Menlo Park: Addison Wesley.

Lyneham, J., Parkinson, C. & Denholm, C. (2008). Explicating Benner’s concept of expert practice: intuition in emergency nursing. Journal of Advanced Nursing 64, 380-387.

Patel, V. L. & Groen, G. J. (1991). Chapter 4: The nature of medical expertise: a critical look. In: Toward a general theory of expertise, pp.93-123. (Ericsson, K. A. & Smith, J., eds.). Cambridge: Cambridge University Press.

Eva, K. W., Norman, G. R., Neville, A. J., Wood, T. J. & Brooks, L. R. (2002). Expert-novice differences in memory: a reformulation. Teaching and Learning in Medicine 14, 257-263.

Coughlin, L. D. & Patel, V. L. (1987). Processing of critical information by physicians and medical students. Journal of Medical Education 62, 818-828.

Schmidt, H. G. & Boshuizen, H. P. A. (1993). On the origin of the intermediate effects in clinical case recall. Memory and Cognition 21, 338-351.

Feltovich, P. J. & Barrows, H. S. (1994). Issues of generality in medical problem solving. In: Tutorials in Problem-based learning: a new direction in teaching the health professions, pp. 128-141. (Schmidt, H. G. & de Volder, M. L. eds.). Assen: Van Garcum.

Boshuizen, H. P. A. & Schmidt, H. G. (1992). On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cognitive Science 16, 153-184.

Patel, V. L., Groen, G. and Scott, H. S. (1988) Biomedical knowledge in explanations of clinical problems by medical students. Medical Examiner, 22: 398-406.

Patel, V. L., Groen, G. J. & Arocha, J. F. (1990). Medical expertise as a function of task difficulty. Memory and Cognition 18, 394-406.

Norman, G. R., Trott, A. D., Brooks, L. R. & Kinsey-Smith, E. K. (1994). Cognitive differences in clinical reasoning related to postgraduate training. Teaching and Learning in Medicine 6, 114-120.

Joseph, G. M. & Patel, V. L. (1990). Domain knowledge and hypothesis generation in diagnostic reasoning. Medical Decision Making 10, 31-46.

Woods, N. N., Brooks, L. R. & Norman, G. R. (2007). The role of biomedical knowledge in diagnosis of difficult clinical cases. Advances in Health Science Education 12, 417-426.

Woods, N. N., Brooks, L. R. & Norman, G. R. (2005). The value of basic science in clinical diagnosis: creating coherence among signs and symptoms. Medical Education 39, 107-112.

Woods, N. N., Brooks, L. R. & Norman, G. R. (2007). It all makes sense: biomedical knowledge, causal connections and memory in the novice diagnostician. Advances in Health Science Education 12, 405-415.

Charlin, B., Boshuizen, H. P. A., Custers, E. J. & Feltovich, P. J. (2007). Scripts and clinical reasoning. Medical Education 41, 1178-1184.

Schmidt, H. G. & Rikers, R. M. J. P. (2007). How expertise develops in medicine: knowledge encapsulation and illness script formation. Medical Education 41, 1133-1139.

Custers, E. J., Boshuizen, H. P. A. & Schmidt, H. G. (1996). The influence of medical expertise, case typicality and illness script component on case processing and disease probability estimates. Memory and Cognition 24, 384-399.

van Schaik, P., Flynn, D., van Wersch, A., Douglass, A. & Cann, P. (2005). Influence of illness script components and medical practice on medical decision-making. Journal of Experimental Psychology: Applied 11, 187-199.

Bordage, G., Connell, K. J., Chang, R. W., Gecht, M. R. & Sinacore, J. M. (1997). Assessing the semantic content of clinical case presentations: studies of reliability and concurrent validity. Academic Medicine 72 (10 Supplement 1) s37-39.

Nendaz, M. R. & Bordage, G. (2002). Promoting diagnostic problem representation. Medical Education 6, 760-766.

Auclair, F. (2007). Problem formulation by medical students: an observation study. (http://www.biomedcentral.com/1472-6920/7/16). BMC Medical Education 7,16. Accessed 14th March 2012.

Rikers, R. M. J. P., Schmidt, H. G., Boshuizen, H. P. A., Linssen, C. G. M., Wesseling, G. & Paas, F. G. W. C. (2002) The robustness of medical expertise: clinical case processing by medical experts and sub-experts. American Journal of Psychology 115, 609-629.

Kassirer J. P. (2010). Teaching clinical reasoning: case-based and coached. Academic Medicine 85, 1118-1124.

Charlin, B., Tardiff, J. & Boshuizen, H. P. A. (2000). Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Academic Medicine 75, 182-190.

Norman, G. R., Young, M. & Brooks, L. R. (2007). Non-analytical models of clinical reasoning: the role of experience. Medical Education 41, 1140-1145.

Hatala, R. M., Norman, G. R. & Brooks, L. R. (1999). Influence of a single example upon subsequent electrocardiogram interpretation. Teaching and Learning in Medicine 11, 110-117.

Coderre, S., Mandin, H., Harasym, P. H. & Fick, G. H. (2003). Diagnostic reasoning strategies and diagnostic success. Medical Education 37, 695-703.

Young, M., Brooks, L. R. & Norman, G. R. (2007). Found in translation: the impact of familiar symptom descriptions on diagnosis in novices. Medical Education 41, 1146-1151.

Cooper, M. W. (1992). Should physicians be Bayesian agents? Theoretical Medicine and Bioethics 13, 349-361.

Sackett, D. L., Rosenberg, W. M. C., Muir-Gray, J. A., Haynes, B. R. & Richardson, W. S. (1996). Evidence-based medicine: what it is and what it isn’t. British Medical Journal 312, 71-72.

Ellis, J., Mulligan, I., Rowe, J. & Sackett, D. L. (1995). Inpatient general medicine is evidence based. Lancet 346, 407-410.

Doubilet, P. & McNeil, B. J. (1982). Treatment choice in gastric carcinoma: a decision analytical approach. Medical Decision Making 2, 261-274.

McNeil, B. J. & Adelstein, S. J. (1976). Determining the value of diagnostic and screening tests. Journal of Nuclear Medicine 17, 439-448.

Round, A. P. (1999). Teaching clinical reasoning – a preliminary controlled study. Medical Education 33, 480-483.

Elieson, S. W. & Papa, F. J. (1994). The effects of various knowledge formats on diagnostic performance. Academic Medicine 69 (Supplement 10) s81-83.

Miller, R. A. & Masarie Jr, F. E. (1989). Use of the Quick Medical Reference (QMR) program as a tool for medical education. Methods of Information in Medicine 28, 340–345.

Ramnarayan, P., Cronje, N., Brown, R. Negus, R., Coode, B., Moss, P., Hassan, T., Hamer, W. & Britto, J. (2007). Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. Emergency Medicine Journal 24, 619-624.

Croskerry, P. (2009). A universal model of clinical reasoning. Academic Medicine 84, 1022-1028.

Graber, M. L., Tompkins, D. & Holland, J. J. (2009). Resources medical students use to derive a differential diagnosis. Medical Teacher 31, 522-527.

Kahneman, D. & Tversky, A. (1979). Prospect theory – an analysis of decisions under risk. Econometrica 47, 263-291.

Bell, D. E. (1982). Regret in decision-making under uncertainty. Operational Research 30, 961-981.

Neale, G., Woloshynowych, M. & Vincent, C. (2001). Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine 94, 322-330.

Scott, I. (2009). Errors in clinical reasoning: causes and remedial strategies. British Medical Journal 339, 22-25.

Shojania, K. G., Burton, E. C., McDonald, K. M. & Goldman, L. (2003). Changes in Rates of Autopsy-Detected Diagnostic Errors Over Time: A Systematic Review. Journal of the American Medical Association 289 (21) 2849-2856.

Kempainen, R. R., Migeon, M. B. & Wolf, F. M. (2003). Understanding our mistakes: a primer on errors in clinical reasoning. Medical Teacher 25, 177-181.

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine 78, 775-780.

Elstein, A. S. (1999). Heuristics and biases selected errors in clinical reasoning. Academic Medicine 74, 791-794.

Croskerry, P. (2002). Achieving quality in clinical decision-making: cognitive strategies and detection of bias. Academic Emergency Medicine 9, 1184-1204.

Groves, M., O’Rourke, P. & Alexander, H. (2003). Clinical reasoning: the relative contribution of identification, interpretation and hypothesis errors to misdiagnosis. Medical Teacher 25, 621-625.

Coderre, S, Wright, B. & McLaughlin, K. (2010). To think is good: querying an initial hypothesis reduces diagnostic error in medical students. Academic Medicine 85, 1125-1129.

Friedman, C. P., Gatti, G. G., Franz, T. M., Murphy, G.C., Wolf, F.M., Heckerling, P.S., Fine, P.L., Miller, T.M. & Elstein, A.S. (2005). Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. Journal of General Internal Medicine 20, 334-339.

Aberreg, S. K., Haponik, E. F. & Terry, P. B. (2005). Omission bias and decision making in pulmonary and critical care medicine. Chest 128, 1497-1505.

Berner, E. & Graber, M. L. (2008). Overconfidence as a cause of diagnostic error in medicine. American Journal of Medicine 121 (Supplement 5) s2-23.

Croskerry, P. & Norman, G. R. (2008), Overconfidence in clinical decision-making. American Journal of Medicine 121 (Supplement 5) s24-29.

Tiedens, L. & Linton, S. (2001). Judgement under emotional certainty and uncertainty: the effects of specific emotions on information processing. Journal of Personality and Social Psychology 81, 973-988.

Croskerry, P. (2003). Cognitive forcing strategies in clinical decision-making. Annals of Emergency Medicine 41, 110-120.

Schon, D. (1987). Educating the Reflective Practitioner. San Francisco: Jossey Bass.

Kolb, D. A. (1984). Experiential Learning. New Jersey: Prentice Hall.

Ark, T. K., Brooks, L. R. & Eva, K. W. (2007). The benefits of flexibility: the pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies. Medical Education 41, 281-287.

Dowie, J. (2006). A new map of the world of judgement and decision-making in health. http://cafeannalisa.wordpress.com/article/judemakia-a-map-of-the-world-of-2rrcx2o0qipsa-2/). Café Annalisa. (Accessed 14th March 2012).

Eva, K. W., Hatala, R. M., LeBlanc, V. R. & Brooks, L. R. (2007). Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information. Medical Education 41, 1152-1158.

Atkinson, K., Ajjawi, R. & Cooling, N. (2011). Promoting clinical reasoning in general practice trainees: role of the clinical teacher. Clinical Teacher 8, 176-180.

Ark, T. K., Brooks, L. R. & Eva, K. W. (2006). Giving learners the best of both worlds: do clinical teachers need to guard against teaching pattern recognition to novices? Academic Medicine 81, 405-409.

Evans, J. S. (2008). Dual processing accounts of reasoning, judgement and social cognition. Annual Review of Psychology 59, 255–278.

Norman, G. R. & Eva, K. W. (2010). Diagnostic error and clinical reasoning. Medical Education 44, 94-100.

Peile, E. (2007). View from education. British Medical Journal 335, 207-208.

Norman, G. R. (2006). Building on experience – the development of clinical reasoning. New England Journal of Medicine 355 (21) 2251-2252.

Bowen, J. L. (2006). Educational strategies to promote clinical diagnostic reasoning. New England Journal of Medicine 335, 2217-2225.

Borleffs, J. C., Custers, E. J., van-Gijn, J. & ten Cate, O. T. (2003). ‘Clinical reasoning theatre’: a new approach to clinical reasoning education. Academic Medicine 78 (3) 322-325.

Elizondo-Omaña, R. E., Morales-Gómez, J. A., Morquecho-Espinoza, O., Hinojosa-Amaya, J. M., Villarreal-Silva, E. E., García-Rodríguez, M. de L. & Guzmán-López, S. (2010). Teaching skills to promote clinical reasoning in early basic science courses. Anatomical Sciences Education 3, 267-271.

Jacobson, K., Fisher, D. L., Hoffman, K. & Tsoulas, K. D. (2010). Integrated Cases Section: a course designed to promote clinical reasoning in year 2 medical students. Teaching and Learning in Medicine 22, 312-316.

Durak, H. I., Caliskan, S. A., Bor, S. & van der Vleuten, C. P. M. (2007). Use of case-based exams as an instructional teaching tool to teach clinical reasoning. Medical Teacher 29 (6) e170-174.

Koriat, A., Lichtenstein, S. & Fischoff, B. (1980). Reasons for overconfidence. Journal of Experimental Psychology 6, 107-118.




DOI: http://dx.doi.org/10.5750/ejpch.v1i1.641

Refbacks

  • There are currently no refbacks.