Understanding context specificity:the effect of contextual factors on clinical reasoning

Background: Situated cognition theory argues that thinking is inextricably situated in a context. In clinical reasoning, this can lead to context specificity: a physician arriving at two different diagnoses for two patients with the same symptoms, findings, and diagnosis but different contextual factors (something beyond case content potentially influencing reasoning). This paper experimentally investigates the presence of and mechanisms behind context specificity by measuring differences in clinical reasoning performance in cases with and without contextual factors. Methods: An experimental study was conducted in 2018-2019 with 39 resident and attending physicians in internal medicine. Participants viewed two outpatient clinic video cases (unstable angina and diabetes mellitus), one with distracting contextual factors and one without. After viewing each case, participants responded to six open-ended diagnostic items (e.g. problem list, leading diagnosis) and rated their cognitive load. Results: Multivariate analysis of covariance (MANCOVA) results revealed significant differences in angina case performance with and without contextual factors [Pillai's trace = 0.72, F=12.4, df=(6, 29), p Conclusions: Using typical presentations of common diagnoses, and contextual factors typical for clinical practice, we provide ecologically valid evidence for the theoretically predicted negative effects of context specificity (i.e. for the angina case), with large effect sizes, offering insight into the persistence of diagnostic error

Exploring implications of context specificity and cognitive load in residents

Introduction: Context specificity (CS) refers to the variability in clinical reasoning across different presentations of the same diagnosis. Cognitive load (CL) refers to limitations in working memory that may impact clinicians’ clinical reasoning. CL might be one of the factors that lead to CS. Although CL during clinical reasoning would be expected to be higher in internal medicine residents, CL’s effect on CS in residents has not been studied. Methods: Internal medicine residents watched a series of three cases portrayed on videos. Following each case, participants filled out a post-encounter form and completed a validated measure of CL. Results: Fourteen residents completed all three cases. Across cases, self-reported CL was relatively high and there were small to moderate correlations between CL and performance in clinical reasoning (r’s = .43, -.33, -.23). In terms of changing CL across cases, the correlations between change in CL and change in total performance were statistically significantly only in moving from case 1 to case 2 (r = -.54, p =.05). Discussion and Conclusion: Residents self-reported measurements of CL were relatively high across cases. However, higher CL was not consistently associated with poorer performance. We did observe the expected associations when looking at case-to-case change in CL. This relationship warrants further study

Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual “stimulus” to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in board certified internists versus resident physicians. Methods Each participant viewed three videotaped clinical encounters portraying common diagnoses in internal medicine. We explicitly modified the context to assess its impact on performance (patient and physician contextual factors). Patient contextual factors, including English as a second language and emotional volatility, were portrayed in the videos. Physician participant contextual factors were self-rated sleepiness and burnout.. The accuracy of diagnostic and therapeutic reasoning was compared with covariates using Fisher Exact, Mann-Whitney U tests and Spearman Rho’s correlations as appropriate. Results Fifteen board certified internists and 10 resident physicians participated from 2013 to 2014. Accuracy of diagnostic and therapeutic reasoning did not differ between groups despite residents reporting significantly higher rates of sleepiness (mean rank 20.45 vs 8.03, U = 0.5, p < .001) and burnout (mean rank 20.50 vs 8.00, U = 0.0, p < .001). Accuracy of diagnosis and treatment were uncorrelated (r = 0.17, p = .65). In both groups, the proportion scoring correct responses for treatment was higher than the proportion scoring correct responses for diagnosis. Conclusions This study underscores that specific contextual factors appear to impact clinical reasoning performance. Further, the processes of diagnostic and therapeutic reasoning, although related, may not be interchangeable. This raises important questions about the impact that contextual factors have on clinical reasoning and provides insight into how clinical reasoning processes in more authentic settings may be explained by situated cognition theory

Turner syndrome and the evolution of human sexual dimorphism

Turner syndrome is caused by loss of all or part of an X chromosome in females. A series of recent studies has characterized phenotypic differences between Turner females retaining the intact maternally inherited versus paternally inherited X chromosome, which have been interpreted as evidence for effects of X-linked imprinted genes. In this study I demonstrate that the differences between Turner females with a maternal X and a paternal X broadly parallel the differences between males and normal females for a large suite of traits, including lipid profile and visceral fat, response to growth hormone, sensorineural hearing loss, congenital heart and kidney malformations, neuroanatomy (sizes of the cerebellum, hippocampus, caudate nuclei and superior temporal gyrus), and aspects of cognition. This pattern indicates that diverse aspects of human sex differences are mediated in part by X-linked genes, via genomic imprinting of such genes, higher rates of mosaicism in Turner females with an intact X chromosome of paternal origin, karyotypic differences between Turner females with a maternal versus paternal X chromosome, or some combination of these phenomena. Determining the relative contributions of genomic imprinting, karyotype and mosaicism to variation in Turner syndrome phenotypes has important implications for both clinical treatment of individuals with this syndrome, and hypotheses for the evolution and development of human sexual dimorphism

Genomic sister-disorders of neurodevelopment: an evolutionary approach

Genomic sister-disorders are defined here as diseases mediated by duplications versus deletions of the same region. Such disorders can provide unique information concerning the genomic underpinnings of human neurodevelopment because effects of diametric variation in gene copy number on cognitive and behavioral phenotypes can be inferred. We describe evidence from the literature on deletions versus duplications for the regions underlying the best-known human neurogenetic sister-disorders, including Williams syndrome, Velocardiofacial syndrome, and Smith–Magenis syndrome, as well as the X-chromosomal conditions Klinefelter and Turner syndromes. These data suggest that diametric copy-number alterations can, like diametric alterations to imprinted genes, generate contrasting phenotypes associated with autistic-spectrum and psychotic-spectrum conditions. Genomically based perturbations to the development of the human social brain are thus apparently mediated to a notable degree by effects of variation in gene copy number. We also conducted the first analyses of positive selection for genes in the regions affected by these disorders. We found evidence consistent with adaptive evolution of protein-coding genes, or selective sweeps, for three of the four sets of sister-syndromes analyzed. These studies of selection facilitate identification of candidate genes for the phenotypes observed and lend a novel evolutionary dimension to the analysis of human cognitive architecture and neurogenetic disorders

Cognitive, Behavioral, and Neural Consequences of Sex Chromosome Aneuploidy

The X chromosome has played a critical role in the development of sexually selected characteristics for over 300 million years, and during that time it has accumulated a disproportionate number of genes concerned with mental functions. There are relatively specific effects of X‐linked genes on social cognition, language, emotional regulation, visuospatial, and numerical skills. Many human X‐linked genes outside the X–Y pairing pseudoautosomal regions escape X‐inactivation. Dosage differences in the expression of such genes (which constitute at least 15% of the total) are likely to play an important role in male–female neural differentiation, and in cognitive deficits and behavioral characteristics, particularly in the realm of social communication, that are associated with sex chromosome aneuploidies

A review of survival estimates for raptors and owls

This paper reviews the literature on survival estimates for different species of raptors and owls, examines the methods used to obtain the estimates, and draws out some general patterns arising. Estimating survival usually involves the marking of birds so that they can be recognized as individuals on subsequent encounters. Annual survival can then be estimated from: (1) birds ringed at known age (usually as nestlings) and subsequently reported by members of the public (usually as found dead), the ratio of recoveries at different ages being used to calculate annual survival; (2) marked breeding adults, trapped or re-sighted in subsequent years in particular study areas, with the proportion re-trapped (or re-sighted) in each year being taken as the minimum annual survival; (3) live encounter (trapped or re-sighted) of birds marked either as nestlings or breeding adults analysed using the capture–mark–recapture (or re-sighting) methods to estimate annual survival; (4) a combination of reports of known-age dead birds and re-trapping/re-sighting of live birds; (5) use of radio- or satellite-tracking to follow the fates of individuals; and (6) the integration of these methods with other information, such as change in numbers between years, to derive estimates of survival and other demographic parameters. Studies confined to particular areas usually give estimates of ‘apparent annual survival’, because they take no account of birds that leave the area. However, radio- or satellite-tracking makes it possible to estimate true survival, including survival of prebreeders that have low natal-site fidelity (this usually requires satellite telemetry). As in other birds, the preferred method for estimating survival has changed over time, as new and more robust methods of estimation have been developed. Methods 1 and 2 were the first to be developed, but without statistical underpinning, while methods 3–6 were developed later on the basis of formal statistical models. This difference has to be borne in mind in comparing older with newer estimates for particular species. Published survival estimates were found for three species of Cathartidae, one of Pandionidae, 29 of Accipitridae, 12 of Falconidae, one of Tytonidae and nine of Strigidae, almost all from temperate Northern Hemisphere species. In most of these species more than one estimate was available, and in some separate estimates for different age or sex groups. The main patterns to emerge included: (1) a significant tendency for annual adult survival to increase with body weight, smaller species having annual survival rates mainly of 60–70%, medium-sized species having rates mainly in the range 70–90% and the largest having rates of > 90%, in the absence of obvious human-caused losses; (2) a lower survival in the first or prebreeding years of life than in subsequent years; (3) a lack of obvious or consistent differences in survival between the sexes, where these could be distinguished; and (4) in the few species for which enough data were available, a decline in annual survival rates in the later years of life