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Matthew J Weiss, Farhan Bhanji, Patricia S Fontela and Saleem I Razack
To assess the impact of a written cognitive aid on expressed clinical reasoning and quantity and the accuracy of information transfer during resident doctor handover.
This study was a randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover events (10 events per group) from residents in their first PICU rotation using a written handover cognitive aid (intervention) or standard practice (control). Before rounds, an investigator generated a reference standard of the handover event by completing a handover aid. Resident handovers were then audio-recorded and transcribed by a blinded research assistant. The content of this transcript was inserted into a blank handover aid. A blinded content expert scored the quantity and accuracy of the information in this aid according to predetermined criteria and these information scores (ISs) were compared with the reference standard. The same expert also blindly scored the transcripts in five domains of clinical reasoning and effectiveness: (i) effective summary of events; (ii) expressed understanding of the care plan; (iii) presentation clarity; (iv) organisation; (v) overall handover effectiveness. Differences between intervention and control groups were assessed using the Mann–Whitney test and multivariate linear regression.
The intervention group had total ISs that more closely approximated the reference standard (81% versus 61%; p < 0.01). The intervention group had significantly higher clinical reasoning scores when compared by total score (21.1 versus 15.9 points; p = 0.01) and in each of the five domains. No difference was observed in the duration of handover between groups (7.4 versus 7.7 minutes; p = 0.97).
Using a novel scoring system, our simple handover cognitive aid was shown to improve information transfer and resident expression of clinical reasoning without prolonging the handover duration.
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Anna T Cianciolo, Reed G Williams, Debra L Klamen and Nicole K Roberts
Context The process whereby medical students employ integrated analytic and non-analytic diagnostic strategies is not fully understood. Analysing academic performance data could provide a perspective complementary to that of laboratory experiments when investigating the nature of diagnostic strategy. This study examined the performance data of medical students in an integrated curriculum to determine the relative contributions of biomedical knowledge and clinical pattern recognition to diagnostic strategy.
Methods Structural equation modelling was used to examine the relationship between biomedical knowledge and clinical cognition (clinical information gathering and interpretation) assessed in Years 1 and 2 of medical school and their relative contributions to diagnostic justification assessed at the beginning of Year 4. Modelling was applied to the academic performance data of 133 medical students who received their md degrees in 2011 and 2012.
Results The model satisfactorily fit the data. The correlation between biomedical knowledge and clinical cognition was low–moderate (0.26). The paths between these two constructs and diagnostic justification were moderate and slightly favoured biomedical knowledge (0.47 and 0.40 for biomedical knowledge and clinical cognition, respectively).
Conclusions The findings suggest that within the first 2 years of medical school, students possessed separate, but complementary, cognitive tools, comprising biomedical knowledge and clinical pattern recognition, which contributed to an integrated diagnostic strategy at the beginning of Year 4. Assessing diagnostic justification, which requires students to make their thinking explicit, may promote the integration of analytic and non-analytic processing into diagnostic strategy.
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Medical Education 2012: 46
Context Clinical reasoning lies at the heart of medical practice and has been the subject of scholarly inquiry and research for some decades. However, despite this, it is still poorly understood. This is largely because current theoretical models are limited in their explanatory power because they are based on particular assumptions of what constitutes clinical reasoning.
Discussion A variety of ways of articulating and conceptualising clinical reasoning can provide us with richer means of understanding what is involved in clinical encounters. A dialogical approach to clinical reasoning is proposed. Dialogism provides a vocabulary that encourages us to integrate insights from different frameworks in ways that combine the strengths of each. Dialogism also puts a focus on the complex ways in which we use language in clinical reasoning to generate meaning. The complexity of language includes narrative, rhetoric and metaphor.
Conclusions A dialogical approach does not require us to discard the findings of earlier theories about clinical reasoning, but provides us with a means of integrating what we know in ways that are more useful in the reality of clinical practice.
Charlin et al.
Medical Education 2012: 46: 454–463
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Chamberland M, St-Onge C, Setrakian J, Lanthier L, Bergeron L, Bourget A, Mamede S, Schmidt H, Rikers R.The influence of medical students’ self-explanations on diagnostic performance. Medical Education; Volume 45, Issue 7, July 2011, Pages: 688–695