A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions

Abstract

BackgroundCognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error).MethodsUsing the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures.ResultsAmong 14 participants, there were 3 cognitive disposition to respond categories – Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities – with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070).ConclusionThis study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.Electronic supplementary materialThe online version of this article (10.1186/s12909-018-1372-2) contains supplementary material, which is available to authorized users.

The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians’ Think-Aloud Reflections

“…From a research perspective, these findings support the value of empirical work using situated cognition to explore context; reasoning differs in the presence of inhibiting contextual factors. Furthermore, while scholars are beginning to examine the cognitive processes and emotions inherent in physicians' clinical reasoning [9,11,20,21,51], to the best of our knowledge, agency has not yet been addressed. Future research could investigate, for example, whether experiences of agency shift between clinic and inpatient contexts or between patients of different cultural backgrounds, and, if so, whether this affects clinical reasoning.…”

“…But some emotional arousal is present in all reasoning [19], particularly in the high-stakes context of patient care, where anxiety and stress often exist [9]. Negative emotions like anxiety can cause a narrowing of attention and risk aversion (along with potentially resultant narrowing of cognitive capacity and increasing cognitive load), which, in turn, can increase the chance of medical error in the form of missed or delayed diagnoses [11,[20][21][22]. Positive emotions can often support reasoning, but they can also lead to overconfidence which can, in turn, result in less information gathering during a patient encounter [11,20,23].…”

“…diagnostic imaging, laboratories) -to eventually reason to a decision. Yet, as discussed earlier, physicians may feel uncertain or anxious in the presence of contextual factors, letting their emotions guide their reasoning [20,21,24]. We approach this through the lens of agency (broadly defined as the capacity to produce an effect [7,8]), exploring whether contextual factors affect how physicians talk about themselves as agents (or not) of the reasoning process.…”

Cognitive bias and medical errors

“…Thinking aloud and discussing the differential diagnosis has been shown to improve the physician's self-rating of bias, but it has been more difficult to demonstrate differences in outcomes. [6][7][8] Clearly more work is needed, and the Journal of the American Academy of Dermatology welcomes studies that present new information on cognitive bias, medical errors, and patient safety.…”

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process

“…These contextual factors (e.g., misleading diagnostic suggestion, language barrier, burnout, etc.) can impede physicians' ability to collect appropriate evidence (e.g., not asking about certain symptoms due to challenges with processing information provided) or with the use of that evidence to make an appropriate diagnosis (e.g., ignoring certain symptoms due to uncertainty contextual factors create about patient reliability) [16,17].…”