Abstract
Clinicians are believed to use two predominant reasoning strategies: system 1 based pattern recognition, and system 2 based analytical reasoning. Balancing these cognitive reasoning strategies is widely believed to reduce diagnostic error. However, clinicians approach different problems with different reasoning strategies. This study explores whether clinicians have insight into their problem specific reasoning strategy, and whether this insight can be used to balance their reasoning and reduce diagnostic error. In Experiment 1, six medical residents interpreted eight ECGs and self-reported their predominant reasoning strategy using a four point scale (4S). Self-assessed reasoning strategy correlated with objective assessment by two clinical experts using a post hoc talk-aloud protocol (ρ = 0.69, p < 0.0001). Reporting an analytic strategy was also associated with 40% longer interpretation times (p = 0.01). In Experiment 2, twenty-four residents were asked to reinterpret eight ECGs with instructions customized to their 4S. Half of the ECGs were reinterpreted with instructions to use the opposite reasoning strategy to that reported, and half with instructions to use the same reasoning strategy. ECG reinterpretation scores did not differ with potentiating compared to balancing reasoning instructions (F1,188 = 0.22, p = 0.64). However, analytic instructions were associated with improved scores (F1,188 = 15, p < 0.0001). These data suggest that clinicians are able to recognize their reasoning strategies. However, attempting to balance reasoning strategies through customizable instructions did not result in a reduction in diagnostic errors. This suggests important limitations to the widespread belief in balancing reasoning strategies to reduce diagnostic error.
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Ark, T., Brooks, L., & Eva, K. (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.
Ark, T., Brooks, L., & Eva, K. (2007). The benefits of flexibility: The pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies. Medical Education, 41(3), 281–287.
Berner, E., & Graber, M. (2008). Overconfidence as a cause of diagnostic error in medicine. American Journal of Medicine, 121, S2–S23.
Boltri, J., Hash, R., & Vogel, R. (2003). Are family practice residents able to interpret electrocardiograms? Advances in Health Sciences Education, 8(2), 149–153.
Croskerry, P. (2005). The theory and practice of clinical decision making. Canadian Journal of Anesthesia, 52, R1–R8.
Croskerry, P. (2009). A universal model of diagnostic reasoning. Academic Medicine, 84, 1022–1028.
Davis, D., Mazmanian, P., Fordis, M., Van Harrison, R., Thorpe, K., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. Journal of American Medical Association, 296(9), 1094–1102.
Dory, V., Gagnon, R., & Charlin, B. (2010). Is case-specificity content-specificity? An analysis of data from extended-matching questions. Advances in Health Sciences Education, 15, 55–63.
Dubin, D. (1967). Rapid interpretation of EKG’s. Tampa: COVER Publishing Company.
Eslava, D., Dhillon, S., Berger, J., Homel, P., & Bergmann, S. (2009). Interpretation of electrocardiograms by first-year residents: The need for change. Journal of Electrocardiology, 42(6), 693–697.
Eva, K., & Cunnington, J. (2006). The difficulty with experience: does practice increase susceptibility to premature closure. Journal of Continuing Educational of Health Professionals, 26, 192–198.
Eva, K., Hatala, R., LeBlanc, V., & Brooks, L. (2007). Teaching from the clinical reasoning literature: Combined reasoning strategies help novice diagnosticians overcome misleading information. Medical Education, 41, 1152–1158.
Evans, J. (2008). Dual processing accounts of cognitive reasoning, judgment and social cognition. Annals Review of Psychology, 59, 255–278.
Gigerenzer, G., & Todd, P. (1999). Simple heuristics that make us smart. Oxford: Oxford University Press.
Graber, M. (2009). Educational strategies to reduce diagnostic error: Can you teach this stuff? Advances in Health Science Education, 14, 63–69.
Graber, M., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165, 1493–1499.
Hatala, R., Norman, G. R., & Brooks, L. R. (1999). Impact of a clinical scenario on accuracy of electrocardiogram interpretation. Journal of General Internal Medicine, 14(2), 126–129.
Hoyle, R., Walker, K., Thomson, G., & Bailey, M. (2007). Accuracy of electrocardiogram interpretation improves with emergency medicine training. Emergency Medicine Australasia, 19(2), 143–150.
Kulatunga-Moruzi, C., Brooks, L., & Norman, G. (2001). Coordination of analytic and similarity-based processing strategies and expertise in dermatological diagnosis. Teaching and Learning in Medicine, 13(2), 110–116.
LeBlanc, V., Dore, K., Norman, G., & Brooks, L. (2004). Limiting the playing field: does restricting the number of possible diagnoses reduce errors due to diagnosis-specific feature identification? Medical Education, 38(1), 17–24.
Lever, N., Larsen, P., Dawes, M., Wong, A., & Harding, S. (2009). Are our medical graduates in New Zealand safe and accurate in ECG interpretation? New Zealand Medical Journal, 122(1292), 9–15.
McLaughlin, K., Coderre, S., Mortis, G., & Mandin, H. (2007). Can concept sorting provide a reliable, valid and sensitive measure of medical knowledge structure? Advances in Health Science Education, 12, 265–278.
McLaughlin, K., Rikers, R., & Schmidt, H. (2008). Is analytic information processing a feature of expertise in medicine? Advances in Health Sciences Education, 13, 123–128.
Norman, G. (2009). Dual processing and diagnostic errors. Advances in Health Science Education, 14, 37–49.
Norman, G., Bordage, G., Page, G., & Keane, D. (2006). How specific is case specificity? Medical Education, 40(7), 618–623.
Norman, G., & Eva, K. (2010). Diagnostic error and clinical reasoning. Medical Education, 44(1), 94–100.
Pretz, J. (2008). Intuition versus analysis: Strategy and experience in complex everyday problem solving. Memory and Cognition, 36(3), 554–566.
Redelmeler, D. (2005). The cognitive psychology of missed diagnoses. Annals of Internal Medicine, 142, 115–120.
Regehr, G., Cline, J., Norman, G., & Brooks, L. (1994). Effect of processing strategy on diagnostic skill in dermatology. Academic Medicine, 69(10 Suppl), S34–S36.
Salerno, S., Alguire, P., & Waxman, H. (2003a). Competency in interpretation of 12-lead electrocardiograms: A summary and appraisal of published evidence. Annals of Internal Medicine, 138(9), 751–760.
Salerno, S., Alguire, P., & Waxman, H. (2003b). Training and competency evaluation for interpretation of 12-lead electrocardiograms: Recommendations from the American College of Physicians. Annals of Internal Medicine, 138(9), 747–750.
Schiff, G., Hasan, O., Abrams, R., Cosby, K., Lambert, B., Elstein, A., et al. (2009). Diagnostic error in medicine: Analysis of 583 physician-reported errors. Archives of Internal Medicine, 169(20), 1881–1887.
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 American Medical Association, 289(21), 2849–2856.
Sim, J., & Wright, C. (2005). The kappa statistic in reliability studies: Use, interpretation and sample size requirements. Physical Therapy, 85, 257–268.
Tversky, A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 211, 453–458.
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Sibbald, M., de Bruin, A.B.H. Feasibility of self-reflection as a tool to balance clinical reasoning strategies. Adv in Health Sci Educ 17, 419–429 (2012). https://doi.org/10.1007/s10459-011-9320-5
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DOI: https://doi.org/10.1007/s10459-011-9320-5