Study of Situation-dependent Clinical Cognition: a Meta-analysis and Preliminary Method

Abstract:

An integrated method was constructed for the study of in situ clinical reasoning. A meta-analysis of existing theories and an exploratory case study were performed. Twelve physicians at the department of otorhinolaryngology, and three physicians and three biomedical technologists at the clinical microbiological laboratory of an 800-bed university hospital were involved in the evaluation of the method. The meta-analysis identified situations where practitioners face assignments for which they follow no routine strategy as suitable starting points for the development of the method, in which organizational processes are presented as workflow graphs. Using the critical incident technique, problem situations in the processes are identified, and stimulated recall interviews are employed to construct a model of the situation-dependent logic used in decision-making. The case study showed thatthe first levels of the method could easily be used by physicians without training in organizational development or cognitive psychology. It is concluded that the method can be a means for case construction in problem-oriented learning programs that have an empirical background. It can also be used in the development of clinical organization, where training is combined with the establishment of critical paths and computer support.

Keywords:

Clinical Cognition - Methodology Design - Meta-analysis - Case Study - Case-based Learning

• References

• 1 Eisenberg JM. Sociological influences on decision making by clinicians. Ann Intern Med 1979; 90: 957-64.
• 2 Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving. Cambridge: Harvard University Press; 1978
• 3 Goran MJ, Williamson JW, Gonella JS. The validity of patient management problems. J Med Educ 1973; 48: 171-7.
• 4 Williams SM. Putting case-based learning into context: examples from legal, business and medical education. J Learn Sci 1993; 2: 367-427.
• 5 Strauss A, Fagerhaugh S, Suzek B, Wiener C. Social Organization of Medical Work. Chicago: The University of Chicago Press; 1986
• 6 Elstein AS, Shulman LS, Sprafka SA. Medical problem solving: a ten-year perspective. Eval Health Professions 1990; 13: 5-36.
• 7 Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise; theory and implications. Acad Med 1990; 65: 611-21.
• 8 Foldevi M. Undergraduate medical students’ rating of clerkship in general practice. Fam Pract 1995; 20: 207-13.
• 9 Timpka T. Situated clinical cognition. Editorial. Artif Intell Med 1995; 7: 387-94.
• 10 Oxman AD, Guyatt GH. Guidelines for reading literature reviews. Can Med Assoc J 1988; 138: 697-703.
• 11 Yin RK. Case Study Research: Design and Methods. London: Sage Publications; 1994
• 12 Areskog NH. The new medical education at the faculty of health sciences, Linkoping University: a challenge for both students and teachers. Scand J Soc Med 1992; 20: 1-4.
• 13 Weber M. Economy and Society. Vol 1 Roth G, Wittich C. eds New York: Bedminster Press; 1968
• 14 Ovretveit J. Health Services Quality. Oxford: Blackwells; 1992
• 15 Parsons T. The Social System. New York: The Free Press; 1951
• 16 Schneider W, Shriffin RM. Controlled and automated human information processing: I. Detection, search and attention. Psych Rev 1977; 84: 1-66.
• 17 Freidsson E. The centrality of professionalism in health care. Jurimetrics 1990; 30: 431-45.
• 18 Argyris C. Why individuals and organizations have difficulties in double-loop learning. In: Argyris C. eds. On Organizational Learning. Oxford: Blackwells; 1994: 7-38.
• 19 Ackoff R. Creating the Corporate Future. New York: Wiley; 1981
• 20 Vermont J, Weil G, Pagonis D, Moutet F, Chapel A, Demongeot J. Conception of a computer-assisted surgical workstation. In: Timmers T, Blum BI. eds. Software Engineering in Medical Informatics. Amsterdam: Elsevier; 1991: 367-83.
• 21 Johnson PS, McLaughlin CP. Measurement and statistical analysis in CQI. In: McLaughlin CP. eds. Continuous quality improvement in health care: theory, implementation and applications. Gaithersburg: Aspen Publications; 1994: 70-101.
• 22 Sjöberg C, Timpka T. Inside multi-disciplinary design in medical informatics: experiences from the use of an argumentative design method. In: Greenes RA, Peterson HE, Protti DJ. eds. Proc MedInfo ’95. Amsterdam: Elsevier; 1995: 1579-83.
• 23 Gärtner J, Wagner I. Systems as intermediaries: political frameworks of design and participation. In: Anderson W. eds. Proceedings of Participatory Design ’94. Chapel Hill: CPSR; 1994: 37-46.
• 24 Evans DA. Issues of cognitive science in medicine. In: Evans DA, Patel VM. eds. Cognitive Science in Medicine. Cambridge, Mass.: MIT Press; 1989: 1-20.
• 25 Patel VL, Groen GJ. Knowledge-based solution strategies in medical reasoning. Cogn Sci 1986; 10: 91-116.
• 26 Patel VL, Groen GJ, Arocha IF. Medical expertise as a function of task difficulty. Memory and Cognition 1990; 18: 394-406.
• 27 Bergus GR, Chapman GB, Gjerde C, Elstein AS. Clinical reasoning about new symptoms despite preexisting disease: sources of error and order effects. Fam Med 1995; 27: 317-20.
• 28 Lemieux M, Bordage G. Structuralisme et pedagogie medicale: etude comparative des strategies cognitives d’apprentis-medecins. Recherches Semiotiques 1986; 6: 143-79.
• 29 Koedinger KR, Anderson JR. Abstract planning and perceptual chunks: elements of expertise in geometry. Cogn Sci 1990; 14: 511-50.
• 30 Nisbett RE, Wilson TD. Telling more than we know: Verbal reports on mental processes. Psych Review 1977; 84: 231-57.
• 31 Kuipers B, Kassirer JP. Causal reasoning in medicine: analysis of a protocol. Cogn Sci 1984; 8: 363-85.
• 32 Aanstoos CM. A critique of the computational model of thought: the contribution of Merleau-Ponty. J Phenomenol Psych 1987; 18: 187-200.
• 33 Newell A, Simon HA. Human Problem Solving. Englewood Cliffs, NJ: Prentice-Hall; 1972
• 34 Winograd T. Language as a Cognitive Process. Vol 1. Syntax. San Francisco: Addison-Wesley; 1982
• 35 Greimas AJ. Structural Semantics. Lincoln: University of Nebraska Press; 1983
• 36 Patel VL, Groen GJ, Fredrikson CH. Differences between students and physicians in memory for clinical cases. Med Educ 1986; 20: 3-9.
• 37 Boshuisen HPA, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediaries and novices. Cogn Sci 1992; 16: 153-84.
• 38 Lemieux M, Bordage G. Propositional versus structural semantic analysis of medical diagnostic thinking. Cogn Sci 1992; 16: 185-204.
• 39 Flanagan JC. The critical incident technique. Psych Bull 1954; 51: 327-58.
• 40 Hayes DM, Fleury RA, Jackson TB. Curriculum content from critical incidents. Med Educ 1979; 13: 175-82.
• 41 Timpka T, Ekström M, Buur T. Information needs and information seeking behavior in primary health care. Scand J Prim Health Care 1989; 7: 105-9.
• 42 Erickson F. Some approaches to inquiry in school-community ethnography. Anthropology and Education Quarterly 1977; 8: 58-69.
• 43 Arborelius E, Timpka T. In what way may videotapes be used to get significant information about the patient-physician relationship. Med Teacher 1990; 12: 194-208.
• 44 Wood ML. Communication between cancer specialists and family doctors. Can Fam Physician 1993; 39: 49-57.
• 45 Rasmussen J, Pejtersen AJ, Goodstein LP. Cognitive Systems Engineering. New York: Wiley; 1994
• 46 Blumer H. The methodological position of symbolic interactionism. In: Blumer H. Symbolic Interactionism. Perspective and Method. Berkeley: University of California Press; 1969: 1-60.
• 47 Collins R. On the microfoundations of macrosociology. Am J Sociol 1981; 86: 984-1014.
• 48 Bouhuijs PAJ, Gijselars A. Course construction in problem-based learning. In: Bouhuijs PAJ, Schmidt HG, van Berkel HJM. eds. Problem-based Learning as an Educational Strategy. Maastricht: The Network for Community-oriented Educational Institutions for Health Sciences; 1993
• 49 Adams L, Kasserman J, Yearwood A. et al. The effect of fact versus problem oriented acquisition. Memory and Cognition 1988; 16: 167-75.
• 50 Drury CG. Task analysis methods in industry. Appl Ergonomics 1983; 14: 19-28.
• 51 Patrick J. Training: Research and Practice. San Diego: Academic Press; 1992
• 52 Garfinkel H. Studies in Ethnomethodology. Englewood Cliffs NJ: Prentice-Hall; 1967
• 53 Ellegård K, Engström T, Nilsson H. Reforming industrial work: principles and realities in the planning of Volvo’s assembly plant in Uddevalla. Stockholm: The Swedish Work Environment Fund; 1990
• 54 Graybeal K, Gheen M, McKenna B. Clinical pathway development: the Overlake model. Nursing Management 1993; 24: 42-5.
• 55 Glass GV, McGaw B, Smith M. Meta-analysis in Social Research. Newbury Park: Sage Publications; 1981
• 56 Knapfl KA, Howard MJ. Interpreting and reporting qualitative research. Research in Nursing and Health 1984; 7: 17-24.
• 57 Thome S. Secondary analysis in qualitative research. In: Morse JM. eds. Critical Issues in Qualitative Research Methods. London: Sage Publ; 1994: 263-79.
• 58 Paton R. Power in organizations: power visible and invisible. In: Armson R, Paton R. eds. Organizations.’ Cases, Issues, Concepts. London: Chapman; 1994: 190-200.
• 59 Brown JS, Collins A, Duguid P. Situated cognition and the culture of learning. Educational Researcher 1989; 18: 32-42.
• 60 Lave J. Cognition in Practice: Mind, Mathematics and Culture in Everyday Life. New York: Cambridge Univ Press; 1988