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

Post-Diagnosis: A Networked Framework for Narrative Reassemblage

This dissertation examines the relationship between diagnostic communication practices and deliberative rhetoric through the lens of Actor-Network theory and feminist theory. Specifically, I argue that Bruno Latour\u27s Actor-Network Theory (ANT) provides a generative framework for tracing diagnostic networks as it accounts for uncertainty, dispersed agency, community stakeholders, and nonhumans. The chapters explore how a networked approach to diagnosis opens up opportunities to reform doctor-patient relationships, expands our conceptions of diagnostic actants, suggests ways to respond to patients living at risk for disease, and broadens our understanding of ethos in healthcare contexts. Furthermore, I also consider how a networked framework can help us comprehend how public misdiagnoses happen so we can prevent them in the future. I conclude by advocating for healthcare providers to reform diagnostic communication practices to account for the agency and expertise of non-specialist stakeholders, particularly patients. I also explore methods for intervening within global health networks and addressing the intersectional problems they collaboratively solve

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

Navigating complexity of child abuse through intuition and evidence-based guidelines: a mix-methods study among child and youth healthcare practitioners

Abstract Background Dutch child and youth health care (CYHC) practitioners monitor and assess the well-being of children. One of their main concerns is identifying cases of child abuse, which is an arduous and sensitive task. In these contexts, CYHC-practitioners use both evidence-based guidelines aimed at increasing the quality of care through rationalised decision-making, and intuition. These two practices are seen as being at odds with each other, yet empirical research has shown that both are necessary in healthcare. This study aims to unravel how intuition is perceived and used by Dutch CYHC-practitioners when identifying and working with cases of child abuse, and how this relates to their evidence-based guidelines. Methods A sequential exploratory mixed-methods design: in-depth semi-structured interviews with CYHC-physicians focused on perceptions on intuition, which were followed by a survey amongst CYHC-practitioners on the recognition and use of the concept. Results The majority of CYHC-practitioners recognise and use intuition in their daily work, stating that it is necessary in their profession. CYHC-practitioners use intuition to 1) sense that something is ‘off’, 2) differentiate between ‘normal’ and ‘abnormal’, 3) assess risks, 4) weigh secondary information and 5) communicate with parents. At the same time, they warn of its dangers, as it may lead to ‘tunnel vision’ and false accusations. Conclusion Intuition is experienced as an integral part of the work of CYHC-practitioners. It is understood as particularly useful in cases of child abuse, which are inherently complex, as signs and evidence of abuse are often hidden, subtle and unique in each case. CYHC-practitioners use intuition to manage and navigate this complexity. There is an opportunity for guidelines to support reflection and intuition as a ‘good care’ practice. </jats:sec

Dementia, Treatment Decisions, and the UN Convention on the Rights of Persons With Disabilities. A New Framework for Old Problems

The UN Convention on the Rights of Persons with Disabilities has been at the center of considerable debate in the field of mental health. The discussion has caught up in particular after the publication of General Comment No. 1 in which the Committee on the Rights of Persons with Disabilities proposes a particularly radical interpretation of Article 12 of the Convention. Such a document has triggered skeptic and at times hostile reactions especially by psychiatrists, together with some positive comments. In this context, there is sometimes the tendency to focus only on the problematic aspects of the rights and support based model proposed by the CRPD and its Committee, forgetting that also “pre-CRPD” legislations on legal capacity present significant shortcomings. In this contribution I focus on the paradigmatic case of treatment decisions of people living with dementia with the aim to show how a number of provisions emerging from the CRPD and General Comment No. 1 can contribute to overcome the issues characterizing the traditional model of legal capacity and consent to treatment. First, I provide a brief overview of the provisions contained in the CRPD and General Comment No.1, summarizing the debate in this area. Then, I move to the case of treatment decisions of people living with dementia, analysing the main issues posed by the traditional model of capacity still characterizing European legislations. I will show how such problems and the solutions previously advanced by academics and practitioners resound in many ways with those identified by the CRPD and its Committee. In the second part, I analyse one by one the main provisions proposed by the CRPD and the Committee, studying how they can be applied in the area of treatment decisions of people living with dementia. In this context I point out the possible interpretations of the various provisions and their pros and cons, also referring to ongoing initiatives providing an insight on how such norms might work in practice

Visual-Linguistic Semantic Alignment: Fusing Human Gaze and Spoken Narratives for Image Region Annotation

Advanced image-based application systems such as image retrieval and visual question answering depend heavily on semantic image region annotation. However, improvements in image region annotation are limited because of our inability to understand how humans, the end users, process these images and image regions. In this work, we expand a framework for capturing image region annotations where interpreting an image is influenced by the end user\u27s visual perception skills, conceptual knowledge, and task-oriented goals. Human image understanding is reflected by individuals\u27 visual and linguistic behaviors, but the meaningful computational integration and interpretation of their multimodal representations (e.g. gaze, text) remain a challenge. Our work explores the hypothesis that eye movements can help us understand experts\u27 perceptual processes and that spoken language descriptions can reveal conceptual elements of image inspection tasks. We propose that there exists a meaningful relation between gaze, spoken narratives, and image content. Using unsupervised bitext alignment, we create meaningful mappings between participants\u27 eye movements (which reveal key areas of images) and spoken descriptions of those images. The resulting alignments are then used to annotate image regions with concept labels. Our alignment accuracy exceeds baseline alignments that are obtained using both simultaneous and a fixed-delay temporal correspondence. Additionally, comparison of alignment accuracy between a method that identifies clusters in the images based on eye movements and a method that identifies clusters using image features shows that the two approaches perform well on different types of images and concept labels. This suggests that an image annotation framework could integrate information from more than one technique to handle heterogeneous images. The resulting alignments can be used to create a database of low-level image features and high-level semantic annotations corresponding to perceptually important image regions. We demonstrate the applicability of the proposed framework with two datasets: one consisting of general-domain images and another with images from the domain of medicine. This work is an important contribution toward the highly challenging problem of fusing human-elicited multimodal data sources, a problem that will become increasingly important as low-resource scenarios become more common

Osteopathic clinical reasoning: an ethnographic study of perceptual diagnostic judgments, metacognition, and reflective practice

A thesis submitted to the University of Bedfordshire in partial fulfilment of the requirements for the degree of Professional DoctorateThis thesis explores the use of reflective practice in osteopathic medicine and uses the method to narrate my work as an osteopathic practitioner. It explores the development of perceptual diagnostic judgments, and the role of metacognition, intuition and palpation in osteopathic clinical reasoning. A qualitative interpretive approach was used with a novel narrative method as an organising structure. This was broadly based around reflective practice models of Gibbs, (1988), Kolb, (1984) and Carper (1978) and the ideas of Schön (1983). Descriptive texts were constructed from notes taken of my thoughts whilst in the presence of patients. This allowed access, as closely as possible, to my decision making process. Finally, the descriptive texts were expanded into narratives through dialogue with the existing literature and peer review. The narratives were then analysed using thematic analysis to derive an understanding of concepts arising from the data. This thesis argues that osteopathic clinical reasoning involves multisensory perceptual diagnostic judgments that begin as soon as the patient enters the clinic, and arise as a result of the use of mental and visual imagery and embodied senses. The multisensory information that is detected by a practitioner activates pattern recognition, analytic reasoning and provides explicit feedback used in decision making. Diagnosis occurs as a result of piecing together and interpreting the multisensory information whilst maintaining awareness of other diagnostic possibilities. The findings also suggest that osteopathic clinical reasoning involves the supervision of cognition by the metacognitive processes of meta-knowledge (MK), meta-experiences (ME), and meta-skills (MS). The latter are used to plan, monitor, analyse, predict, evaluate and revise the consultation and patient management as suggested by Pesut and Herman (1992). ME is demonstrated by the presence of judgments of learning used to ensure sufficient information has been gathered, and feelings of rightness that are used to perceive the correctness of information arriving and decisions made. The use of reflective practice in this research has developed the understanding of osteopathic clinical reasoning, and demonstrated that it provides a powerful conduit for change in practice. As a result, it enables the provision of better patient-centred osteopathic healthcare incorporating the biopsychosocial model of healthcare. Although rooted in my own osteopathic practice style and strategies, it should have resonance for those within the discipline of osteopathy and has implications for osteopathic education, training and research

Information Systems and Healthcare XXXIV: Clinical Knowledge Management Systems—Literature Review and Research Issues for Information Systems

Knowledge Management (KM) has emerged as a possible solution to many of the challenges facing U.S. and international healthcare systems. These challenges include concerns regarding the safety and quality of patient care, critical inefficiency, disparate technologies and information standards, rapidly rising costs and clinical information overload. In this paper, we focus on clinical knowledge management systems (CKMS) research. The objectives of the paper are to evaluate the current state of knowledge management systems diffusion in the clinical setting, assess the present status and focus of CKMS research efforts, and identify research gaps and opportunities for future work across the medical informatics and information systems disciplines. The study analyzes the literature along two dimensions: (1) the knowledge management processes of creation, capture, transfer, and application, and (2) the clinical processes of diagnosis, treatment, monitoring and prognosis. The study reveals that the vast majority of CKMS research has been conducted by the medical and health informatics communities. Information systems (IS) researchers have played a limited role in past CKMS research. Overall, the results indicate that there is considerable potential for IS researchers to contribute their expertise to the improvement of clinical process through technology-based KM approaches

Knowledge-based Biomedical Data Science 2019

Knowledge-based biomedical data science (KBDS) involves the design and implementation of computer systems that act as if they knew about biomedicine. Such systems depend on formally represented knowledge in computer systems, often in the form of knowledge graphs. Here we survey the progress in the last year in systems that use formally represented knowledge to address data science problems in both clinical and biological domains, as well as on approaches for creating knowledge graphs. Major themes include the relationships between knowledge graphs and machine learning, the use of natural language processing, and the expansion of knowledge-based approaches to novel domains, such as Chinese Traditional Medicine and biodiversity.Comment: Manuscript 43 pages with 3 tables; Supplemental material 43 pages with 3 table