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

A European perspective on auditory processing disorder-current knowledge and future research focus

Current notions of \u201chearing impairment,\u201d as reflected in clinical audiological practice, do not acknowledge the needs of individuals who have normal hearing pure tone sensitivity but who experience auditory processing difficulties in everyday life that are indexed by reduced performance in other more sophisticated audiometric tests such as speech audiometry in noise or complex non-speech sound perception. This disorder, defined as \u201cAuditory Processing Disorder\u201d (APD) or \u201cCentral Auditory Processing Disorder\u201d is classified in the current tenth version of the International Classification of diseases as H93.25 and in the forthcoming beta eleventh version. APDs may have detrimental effects on the affected individual, with low esteem, anxiety, and depression, and symptoms may remain into adulthood. These disorders may interfere with learning per se and with communication, social, emotional, and academic-work aspects of life. The objective of the present paper is to define a baseline European APD consensus formulated by experienced clinicians and researchers in this specific field of human auditory science. A secondary aim is to identify issues that future research needs to address in order to further clarify the nature of APD and thus assist in optimumdiagnosis and evidence-based management. This European consensus presents the main symptoms, conditions, and specific medical history elements that should lead to auditory processing evaluation. Consensus on definition of the disorder, optimum diagnostic pathway, and appropriate management are highlighted alongside a perspective on future research focus

Bizarre thoughts, magical ideations, and voices from the unconscious: Exploring issues of anomalous experience

This project was initially concerned with the clinical interpretations of ‘bizarre’ or ‘magical’ ideations (i.e., statements considered to have little or no validity in our predominant western culture). The first study explored clinical assessment issues of who determines the validity of expressed beliefs and what kinds of criteria such decisions are based on in the mental health field. The present study examined a particular type of magical ideation, an auditory phenomenon involving claims that forward spoken conversation contains hidden backwards speech embedded in the vocal sounds. Thirty-two participants were invited to listen to various audio samples of the alleged phenomenon and provide interpretations of what was heard. Participants were assigned to four groups, each differing in the level of pre-emptive information. A comparative measure revealed that priming and suggestion could not be dismissed as alternative explanations of the reported effects. Clinical and social implications will be discussed

Motor Performance in Children with Childhood Apraxia of Speech and Speech Sound Disorders

Purpose: This study sought to determine if (a) children with childhood apraxia of speech (CAS), other speech sound disorders (SSDs), and typical development (TD) would perform differently on a standardized motor assessment and (b) whether comorbid language impairment would impact group differences. Method: Speech, language, and motor abilities were assessed in children with CAS (n = 10), SSD (n = 16), and TD (n = 14) between the ages of 43 and 105 months. Motor skills were evaluated using the Movement Assessment Battery for Children-Second Edition (Henderson, Sugden, & Barnett, 2007), a behavioral assessment that is sensitive in identifying fine/gross motor impairments in children with a range of motor and learning abilities. Data were reanalyzed after reclassifying children by language ability. Results: The CAS group performed below the normal limit on all components of the motor assessment and more poorly than the TD and SSD groups on Aiming and Catching and Balance. When children were reclassified by language ability, the comorbid CAS + language impairment group performed worse than the SSD-only and TD groups on Manual Dexterity and Balance and worse than the TD group on Aiming and Catching; all 7 children with CAS + language impairment evidenced performance in the disordered range compared to 1 of 3 children in the CAS-only group and 2 of 6 children in the SSD + language impairment group. Conclusions: Children with CAS + language impairment appear to be at an increased risk for motor impairments, which may negatively impact social, academic, and vocational outcomes; referrals for motor screenings/assessments should be considered. Findings may suggest a higher order deficit that mediates cognitive-linguistic and motor impairments in this population

Using social robots to study abnormal social development

Social robots recognize and respond to human social cues with appropriate behaviors. Social robots, and the technology used in their construction, can be unique tools in the study of abnormal social development. Autism is a pervasive developmental disorder that is characterized by social and communicative impairments. Based on three years of integration and immersion with a clinical research group which performs more than 130 diagnostic evaluations of children for autism per year, this paper discusses how social robots will make an impact on the ways in which we diagnose, treat, and understand autism

Determination and evaluation of clinically efficient stopping criteria for the multiple auditory steady-state response technique

Background: Although the auditory steady-state response (ASSR) technique utilizes objective statistical detection algorithms to estimate behavioural hearing thresholds, the audiologist still has to decide when to terminate ASSR recordings introducing once more a certain degree of subjectivity. Aims: The present study aimed at establishing clinically efficient stopping criteria for a multiple 80-Hz ASSR system. Methods: In Experiment 1, data of 31 normal hearing subjects were analyzed off-line to propose stopping rules. Consequently, ASSR recordings will be stopped when (1) all 8 responses reach significance and significance can be maintained for 8 consecutive sweeps; (2) the mean noise levels were ≤ 4 nV (if at this “≤ 4-nV” criterion, p-values were between 0.05 and 0.1, measurements were extended only once by 8 sweeps); and (3) a maximum amount of 48 sweeps was attained. In Experiment 2, these stopping criteria were applied on 10 normal hearing and 10 hearing-impaired adults to asses the efficiency. Results: The application of these stopping rules resulted in ASSR threshold values that were comparable to other multiple-ASSR research with normal hearing and hearing-impaired adults. Furthermore, in 80% of the cases, ASSR thresholds could be obtained within a time-frame of 1 hour. Investigating the significant response-amplitudes of the hearing-impaired adults through cumulative curves indicated that probably a higher noise-stop criterion than “≤ 4 nV” can be used. Conclusions: The proposed stopping rules can be used in adults to determine accurate ASSR thresholds within an acceptable time-frame of about 1 hour. However, additional research with infants and adults with varying degrees and configurations of hearing loss is needed to optimize these criteria

Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice.

BACKGROUND: Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. METHODS AND RESULTS: Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom durationmodel, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5-9, OR 2.62, 95% CI 1.41-4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29-9.09) and weakness (OR 2.28, 95% CI 1.35-3.85), and negatively associated with symptom duration \u3e270 min (OR 0.41, 95% CI 0.25-0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration \u3c6 \u3eh. CONCLUSION: Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification