Metacognition and Decision-Making Style in Clinical Narratives

Clinical decision-making has high-stakes outcomes for both physicians and patients, yet little research has attempted to model and automatically annotate such decision-making. The dual process model (Evans, 2008) posits two types of decision-making, which may be ordered on a continuum from intuitive to analytical (Hammond, 1981). Training clinicians to recognize decision-making style and select the most appropriate mode of reasoning for a particular context may help reduce diagnostic error (Norman, 2009). This study makes preliminary steps towards detection of decision style, based on an annotated dataset of image-based clinical reasoning in which speech data were collected from physicians as they inspected images of dermatological cases and moved towards diagnosis (Hochberg et al., 2014a). A classifier was developed based on lexical, speech, disfluency, physician demographic, cognitive, and diagnostic difficulty features to categorize diagnostic narratives as intuitive vs. analytical; the model improved on the baseline by over 30%. The introduced computational model provides construct validity for the dual process theory. Eventually, such modeling may be incorporated into instructional systems that teach clinicians to become more effective decision makers. In addition, metacognition, or self-assessment and self-management of cognitive processes, has been shown beneficial to decision-making (Batha & Carroll, 2007; Ewell-Kumar, 1999). This study measured physicians\u27 metacognitive awareness, an online component of metacognition, based on the confidence-accuracy relationship, and also exploited the corpus annotation of decision style to derive decision metrics. These metrics were used to examine the relationships between decision style, metacognitive awareness, expertise, case difficulty, and diagnostic accuracy. Based on statistical analyses, intuitive reasoning was associated with greater diagnostic accuracy, with an advantage for expert physicians. Case difficulty was associated with greater user of analytical decision-making, while metacognitive awareness was linked to decreased diagnostic accuracy. These results offer a springboard for further research on the interactions between decision style, metacognitive awareness, physician and case characteristics, and diagnostic accuracy

Representing and Inferring Visual Perceptual Skills in Dermatological Image Understanding

Experts have a remarkable capability of locating, perceptually organizing, identifying, and categorizing objects in images specific to their domains of expertise. Eliciting and representing their visual strategies and some aspects of domain knowledge will benefit a wide range of studies and applications. For example, image understanding may be improved through active learning frameworks by transferring human domain knowledge into image-based computational procedures, intelligent user interfaces enhanced by inferring dynamic informational needs in real time, and cognitive processing analyzed via unveiling the engaged underlying cognitive processes. An eye tracking experiment was conducted to collect both eye movement and verbal narrative data from three groups of subjects with different medical training levels or no medical training in order to study perceptual skill. Each subject examined and described 50 photographical dermatological images. One group comprised 11 board-certified dermatologists (attendings), another group was 4 dermatologists in training (residents), and the third group 13 novices (undergraduate students with no medical training). We develop a novel hierarchical probabilistic framework to discover the stereotypical and idiosyncratic viewing behaviors exhibited by the three expertise-specific groups. A hidden Markov model is used to describe each subject\u27s eye movement sequence combined with hierarchical stochastic processes to capture and differentiate the discovered eye movement patterns shared by multiple subjects\u27 eye movement sequences within and among the three expertise-specific groups. Through these patterned eye movement behaviors we are able to elicit some aspects of the domain-specific knowledge and perceptual skill from the subjects whose eye movements are recorded during diagnostic reasoning processes on medical images. Analyzing experts\u27 eye movement patterns provides us insight into cognitive strategies exploited to solve complex perceptual reasoning tasks. Independent experts\u27 annotations of diagnostic conceptual units of thought in the transcribed verbal narratives are time-aligned with discovered eye movement patterns to help interpret the patterns\u27 meanings. By mapping eye movement patterns to thought units, we uncover the relationships between visual and linguistic elements of their reasoning and perceptual processes, and show the manner in which these subjects varied their behaviors while parsing the images

Exploring the activities and outcomes of digital teaching and learning of practical skills in higher education for the social and health care professions: a scoping review

Higher education for health care professionals faces numerous challenges. It is important to develop and apply methods supporting education, especially the practical skills. This scoping review aimed to explore the activities and learning outcomes of digital technology in practical skills teaching and learning in higher education for the social and health professions. Scoping review recommendations and the PRISMA-ScR checklist were applied. Randomized controlled trials published between 2016 and 2021 involving students in higher education who were taking courses in the social sciences and health care and reported interventions with digital technology activities and practices in practical teaching and learning were included. The CINAHL Plus, PubMed, Scopus, ERIC, and Sociological Abstracts/Social Services Abstracts databases were searched. Teaching methods were blended, e-learning or other online-based, and digital simulation-based activities. Teaching and learning environments, methods, resources, and activity characteristics varied, making a summary difficult. Interventions were developed in a face-to-face format prior to digitalization. The outcomes were measured at the knowledge level, not at the performance level. One-third of the studies showed a significant improvement in practical skills in the intervention group in comparison to the control conditions. The use of digital technology in the learning and teaching process have potential to develop of students' skills, knowledge, motivation, and attitudes. The pedagogy of technology use is decisive. The development of new digital methods for teaching and learning practical skills requires the engagement of students and teachers, in addition the researchers.publishersversionPeer reviewe

The role of the Dermatology Nurse Practitioner in the Western Cape as perceived by nurses and other health care practitioners

Background information Most dermatologists in South Africa practice in urban areas whereas rural populations have limited access to dermatology services. The first group of dermatology nurses in South Africa was trained in 1997, through a short course programme offered at Groote Schuur Hospital in Cape Town, to increase access to care. These nurses provide dermatological treatment and care in a variety of health care settings; however, their role has not been formally described. Aim of the Study The study aim was to explore and describe the role of a dermatology nurse practitioner at primary and tertiary care in the Western Cape Province, South Africa, as perceived by dermatologists, physicians, dermatology nurse practitioners, non-dermatology trained nurses and nurse managers who have worked with dermatology nurses. Methodology A qualitative, descriptive and exploratory design was selected for the study. Purposive sampling was used to select participants who were doctors and nurses and who had been involved in rendering dermatological services. Participants were drawn from public and private health care institutions at primary and tertiary care levels. Individual interviews, using a semi structured interview schedule, were conducted with three nurses, two medical officers, three nurse managers and four dermatologists. A focus group was conducted with seven dermatology nurse practitioners. Data were analysed using content analysis. Findings The findings show that dermatology nurse practitioners are not only involved in clinical care of patients, but have other roles which include education, management of the services and leadership. The benefits of dermatology nurse practitioners' roles for the patient include increased access to care, improved quality of life and reduced costs. The health system is thought to have benefitted from reduced referrals to tertiary care as more patients are effectively managed at primary care level. Challenges to the role include a lack of support for the dermatology nurse practitioners, inadequate resources and lack of regulation. Recommendations include a call for accreditation of dermatology nursing and provision of learning opportunities for DNPs. The findings of the study may not reflect the experiences and perceptions of practitioners beyond this region as the study was limited to the Western Cape. Conclusion The value of the dermatology nurse practitioners has been appreciated by all stakeholders in this study. If recognised by statutory bodies and the role of the dermatology nurse practitioner is regulated, it has the potential to expand the reach of dermatology services and contribute to the overall health care for persons with skin disorders

An exploration of men's subjective experience of Vitiligo : a qualitative study

Vitiligo is a chronic skin disorder, which de-pigments parts or all of the skin. This disfiguring condition presents individual sufferers with many challenges. Studies have shown an adverse psychological impact of living with such a skin condition. However, no studies to date have explored the experience of vitiligo from a purely male perspective. This study sought to provide some preliminary understanding of and insight into men’s experience of vitiligo. A qualitative design was employed and the study was conducted using semi-structured interviews with six participants from a white British background who were all members of the Vitiligo Society UK. Three arching themes were found: processing the vitiligo diagnosis, focus on self and managing relationships. These findings are relevant to the theoretical understanding of the psychological impact that skin disorders can have on men. The applicability of these findings for Counselling Psychology practice in the management of vitiligo is discussed and future areas for research are suggested

Patient History Elicitation and Diagnostic Decision Making

Technology has changed the way people communicate, and communication between patients and medical professionals has not been exempt from these developments. Clinicians are now text messaging, emailing, and video conferencing patient. Understanding the impact of the new modalities on communication patterns is imperative to ensure quality care. Thirty-two medical professionals of varying experience conducted a patient interview with two confederate patients over an instant messaging system. The first interview was 15 minutes and the second 7 minutes, the latter condition inducing time pressure. The results demonstrated that time pressure has an adverse impact on the medical professionals’ communication patterns. The experience level of the medical professional was a mediating factor with strategies exhibited paralleling those outlined by stages of medical expertise

Roundtable Discussion (RTD03) - Is there a downside to using Simulated Patients to teach and assess communication skills?

Background Simulated Patients (SPs) are widely used to facilitate the learning of communication skills enabling students to receive detailed feedback on experiential practice in a safe environment. They are also used in the assessment of students’ communication skills in Objective Structured Clinical Examinations (OSCEs). We have observed that our most experienced SPs are highly conversant with medical jargon and consultation skills and have almost become ‘medical faculty’. Consultations can therefore lack the true patient perspective, with SPs focussing their feedback on process rather than giving a true patient perspective. Roundtable objectives To consider the challenges in ensuring that highly experienced SPs continue to respond from a true patient perspective To critique whether the use of SPs in OSCE stations is a valid way to assess students’ communication skills with real patients To consider whether using consultations with Simulated Patients is useful for students in the later years of an Undergraduate medical course who are learning to integrate the different components of a consultation and reasoning clinically in a real-life clinical context To share best practice with colleagues Roundtable A brief interactive presentation including the authors’ experiences of working with experienced Simulated Patients which will draw on current literature regarding the evidence for using Simulated Patients in the teaching and assessing of communication skills Delegates will have the opportunity to take part in three roundtable discussions • OSCE Stations using SPs assess how good students are at communicating with SPs but not with real patients • Experienced SPs are in danger of responding with a faculty not a patient perspective • By using SPs in teaching we over focus on process and forget the global picture

WS19. From pedagogy to practice: implementing transformative learning in clinical reasoning

BackgroundHealthcare professionals must provide high quality care that is both efficient and safe. Underpinning this requirement is a presumption that individuals are able to make accurate clinical decisions. Knowledge is not sufficient: judgment and reasoning are required to translate clinical information into accurate decisions to produce effective care. Clinical reasoning skills need to be developed in healthcare professionals in a way that produces change in behaviour. This is aplies to the spectrum of healthcare education: from undergraduate to postgraduate to lifelong practice. Though much is understood about clinical decision-making theory, direction for systematic implementation of teaching in both undergraduate and postgraduate medical education programmes is lacking. In particular, evidence describing transformative teaching methods is limited. This workshop will explore how to design effective spiral curricula in clinical reasoning, compare and contrast experiences from three medical schools in the UK, discuss challenges in implementation, share a variety of teaching methods, provide hands on demonstration of technological resources that have produced changes in learner behaviour and support attendees to adapt methodology to their programmes.Structure of workshopWe will briefly review current knowledge on clinical decision-making learning before sharing experiences from three UK medical schools.Attendees will participate in discussions supported by interactive exercises to explore each subtopic. These exercises will include role play, video and trial of electronic teaching tools used in our current practice. The session will conclude with a reflection on principles and ideas shared during the event