Context and clinical reasoning: understanding the perspective of the expert's voice

Medical Education 2011: 45 : 927–938 OBJECTIVES Prior work has found that a doctor’s clinical reasoning performance varies on a case‐by‐case (situation) basis; this is often referred to as ‘context specificity’. To explore the influence of context on diagnostic and therapeutic clinical reasoning, we constructed a series of videotapes to which doctors were asked to respond, modifying different contextual factors (patient, doctor, setting). We explored how these contextual factors, as displayed by videotape encounters, may have influenced the clinical reasoning of board‐certified internists (experts). Our purpose was to clarify the influence of context on reasoning, to build upon education theory and to generate implications for education practice. METHODS Qualitative data about experts were gathered from two sources: think‐aloud protocols reflecting concurrent thought processes that occurred while board‐certified internists viewed videotape encounters, and free‐text responses to queries that explicitly asked these experts to comment on the influence of selected contextual factors on their clinical reasoning processes. These data sources provided both actual performance data (think‐aloud responses) and opinions on reflection (free‐text answers) regarding the influence of context on reasoning. Results for each data source were analysed for emergent themes and then combined into a unified theoretical model. RESULTS Several themes emerged from our data and were broadly classified as components influencing the impact of contextual factors, mechanisms for addressing contextual factors, and consequences of contextual factors for patient care. Themes from both data sources had good overlap, indicating that experts are somewhat cognisant of the potential influences of context on their reasoning processes; notable exceptions concerned the themes of missed key findings, balancing of goals and the influence of encounter setting, which emerged in the think‐aloud but not the free‐text analysis. CONCLUSIONS Our unified model is consistent with the tenets of cognitive load, situated cognition and ecological psychology theories. A number of potentially modifiable influences on clinical reasoning were identified. Implications for doctor training and practice are discussed.     

Understanding Associations between Information Seeking and Scanning and Health Risk Behaviors: An Early Test of the Structural Influence Model

This study examined proposed direct and mediating relationships in the Structural Influence Model (SIM) of Communication within the chronic disease context. Using data from the Annenberg National Health Communication Survey (N = 14,472), we tested the potential mediating roles of information seeking, information scanning, and social capital between social determinants of health and four chronic disease risk behaviors: exercise level, fruit and vegetable intake, cigarette smoking, and excessive alcohol use. Information seeking, information scanning, and social capital received support as potential mediators. Our results are largely consistent with predictions of the SIM and highlight the important role of communication in reducing health risks and increasing healthy behaviors.     

Enhancing peer review with communication skill building

The purpose of this pilot was to improve the peer review process by enhancing the communication skills of staff nurses. Communication skill building was taught to staff members with practice time allotted. The paradigm shift occurred in teaching staff that communication is a learned skill built through practice and not solely a cognitive skill. The results of this pilot demonstrated improved verbal communication, increased comfort with peer review, improved ability to separate performance from individual style differences, and increased accuracy with which staff rate themselves on self evaluations. An indirect benefit has been improved teamwork from increased support among the staff.     

Clinical Reasoning and Reflective Practice: Implications of Fieldwork Activities

Objectives. Theories and research suggest that learning clinical reasoning skills requires students to be reflective in their practice. To explain this proposition, five research questions were developed to examine the effect of: (a) the fieldwork experience on clinical reasoning skills, (b) degree of participation in different clinical reasoning activities on clinical reasoning skills, and (c) the total number of clinical reasoning activities in which students participated related to clinical reasoning.

Method. Data (n = 70) were collected using a researcher-developed case analysis test, the Adaptive Style Inventory, and a questionnaire. Paired t tests, ANCOVA, and multiple regressions were used to analyze the data from the research questions.

Results. Fieldwork does improve clinical reasoning skills (large effect size). Participation in activities thought to develop clinical reasoning skills was mixed.

Conclusion. The results support the improvement of fieldwork as a mode of developing clinical reasoning skills in occupational therapy students.     

Striving for therapeutic relationships: parent-provider communication in the developmental treatment setting

The purpose of this grounded theory study is to develop a beginning substantive theory that explains the communication process between parents of children receiving center-based services for developmental delays and disabilities and the professional providers of those services. Communication is defined broadly as including both content and relationship dimensions. Twenty parents and 14 providers described their experience of communication with one another. The core phenomenon constructed from the data was striving for therapeutic relationships within a context of uncertainty. Both parents and providers operated in a context of uncertainty regarding the child and his or her development and prospects for the future as well as their expectations of each other. Both parents and providers used strategies of balancing, reading the cues, questioning, managing uncertainty, and managing the sessions. The outcomes were relationships that were valued by the extent to which they were perceived as therapeutic to parents and child.     

A dialogic model of conversations about risk: Coordinating perceptions and achieving quality decisions in cancer care

We propose that academic scholarship and clinical practice should conceptualize communication about risk as a dialogic and relational process. This conceptual paper addresses how clinical decisions about cancer treatment are impacted by different risk perceptions. Patients and health care providers base their risk perceptions on analytic or experiential reasoning processes. However, most risk communication research in the clinical context only examines the transmissive and persuasive communication of these different risk perceptions. This transmissive communication results in a monologic model that limits the opportunities for patients and clinicians to incorporate their perspectives into a shared understanding. The dialogic model of risk communication contributes to a quality cancer care decision because it creates open space to find connections between patient values and clinical evidence while allowing the parties to have a satisfactory level of involvement. The final section of the paper describes theory behind a dialogic perspective and offers guidelines for how to implement it in risk communication to improve clinical decision making.     

Investigating the Effects of Mass Media Exposure on the Uptake of Preventive Measures by Hong Kong Residents during the 2015 MERS Outbreak: The Mediating Role of Interpersonal Communication and the Perception of Concern

In 2015, South Korea experienced the largest outbreak to date of the Middle East Respiratory Syndrome (MERS-CoV) outside the Middle East. Fears related to a potential spread of the disease led to an increased alert level as well as heightened media coverage in the neighboring Hong Kong. A cross-sectional survey (N = 533) among residents of Hong Kong was conducted to assess the relationships between the effects of outbreak-related mass media coverage, interpersonal communication, the perceived level of concern in one’s close environment, and the uptake of preventive measures. A serial multiple mediator model finds that interpersonal communication and higher perceived concern indirectly influence the effects of media coverage on the engagement in preventive actions. These results expand previous research on the mediating role of interpersonal communication and support assumptions about a modified two-step flow of communication in the context of a public health emergency.     

The effects of physical environments in medical wards on medication communication processes affecting patient safety

Physical environments of clinical settings play an important role in health communication processes. Effective medication management requires seamless communication among health professionals of different disciplines. This paper explores how physical environments affect communication processes for managing medications and patient safety in acute care hospital settings. Findings highlighted the impact of environmental interruptions on communication processes about medications. In response to frequent interruptions and limited space within working environments, nurses, doctors and pharmacists developed adaptive practices in the local clinical context. Communication difficulties were associated with the ward physical layout, the controlled drug key and the medication retrieving device. Health professionals should be provided with opportunities to discuss the effects of ward environments on medication communication processes and how this impacts medication safety. Hospital administrators and architects need to consider health professionals' views and experiences when designing hospital spaces.     

Examining HIV/AIDS-Related Stigma at Play: Power,Structure, and Implications for HIV Interventions

ABSTRACT

Drawing on critical theoretical perspectives and ethnographic field research related to HIV/AIDS in northern India, this paper argues for a cultured-centered approach to stigma reduction interventions and communication practices that are based on an assessment of larger social and structural processes on the one hand and the lived experiences and narratives of people living with HIV (PLWH) on the other. This paper suggests that while the complex nature of stigma, particularly as it relates to HIV/AIDS, makes it difficult to understand and respond to, this problem is further exacerbated by a largely individual and behavior-centered research that still dominates the field of Health Communication. Such research sees human cognition as the main source of stigma and underplays issues of power, structure, domination, and control. More specifically, and with concrete examples from the everyday lived experiences of PLWH – such as their experiences within family and health-care settings, this paper demonstrates how power and structure deeply impact their lives and remain central to their experience of (and resistance to) stigma, thus opening up space for alternative theorizing and practices in Health Communication.     

US Latino adolescents’ use of mass media and mediated communication in romantic relationships*

The present study uses uncertainty reduction theory to analyze how Latino adolescents perceive that mass media influence their conceptions of romantic relationships. In addition, we explore how these adolescents use social media in their romantic relationships. Data are from five focus groups with 44 Latino adolescents (M = 16.39 years old; 59% female) in the US Midwest. Findings indicate that Latino adolescents believe media portray unrealistic ideals of romantic relationships, yet these teens also see the portrayals as ideals to which they should aspire. When it comes to social media, the youth perceived one-to-one mediated communication (e.g. Skype) as beneficial to their romantic relationships, but evaluated one-to-many mediated communication (e.g. Facebook, Instagram) as largely negative. Our findings identify three sources of evidence in the latter context that create relational uncertainty: (1) visual, (2) partner communication, and (3) third-party communication.     

Learning to Reason: A Journey of Professional Socialisation

One of the key attributes that health professional students and new graduates develop during professional socialisation is clinical reasoning ability. Clinical reasoning is a complex skill that is essential for professional practice. There is limited research specifically addressing how physiotherapists learn to reason in the workplace. The research reported in this paper addressed this gap by investigating how experienced physiotherapists learned to reason in daily practice. This learning journey was examined in the context of professional socialisation. A hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated, semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants’ learning journeys were diverse, although certain episodes of learning were common or similar. Role models, mentors and colleagues were found to be influential in the development of reasoning. An important implication for the professional socialisation of physiotherapists and other health professionals and for those involved in practice development is the need to recognise and enhance the role of practice communities in the explicit learning of clinical reasoning skills.     

Longitudinal and Concentrated Communication Skills Programmes: Two Dutch Medical Schools Compared

Aim of the study:The communication skills of students of the Dutch medical schools of Maastricht and Leiden were compared, to assess the effectiveness of these schools' different approaches to communication skills training. Both schools have a six-year undergraduate medical curriculum, divided into four preclinical years and two years of clinical clerkships. The Maastricht problem-based curriculum offers an integrated clinical skills training programme, including communication skills, which runs throughout the first four years. Communication skills training in Leiden is concentrated in courses in the preclinical phase, at the beginning of the clinical phase and preceding two clerkships. Method:Communication skills of fourth-year and sixth-year students (N = 161) of both universities were assessed using four OSCE stations in which students did entire consultations with standardised patients. Trained observers rated these consultations, using a checklist. Results:Maastricht students of both year groups obtained significantly higher checklist scores for their communication skills than their Leiden colleagues. The Leiden students' scores increase between years 4 and 6, whereas those of the Maastricht students showed no significant change. Discussion:The higher scores obtained by the Maastricht students indicate a greater overall effectiveness of a longitudinal, integrated approach compared with concentrated courses. Absence of formal training in the clinical phase in Maastricht leads to stabilisation of communication skills, whereas the increase in the Leiden students' scores between years 4 and 6 offers evidence that formal communication skills training during the clinical phase does pay off. These findings suggest that the preferred approach to communication skills training would be an integrated, longitudinal programme, which continues during the clinical years. This revised version was published online in June 2006 with corrections to the Cover Date.     

Changing Women: Mothers and Their Adolescent Daughters

Budding fecundity in the female child is a matter of family concern. The authors used the grounded theory method to explore the process of communication between mothers and their adolescent daughters concerning sexuality issues within the context of the age changes of both. A core category of changing women was identified along with three maternal and three daughter processes. Changes that occur during this time period can lead to lasting separation between the pair if they fail to develop insight as a way of protecting themselves and one another. The findings may assist health professionals to understand these changes and facilitate the process of communication in these dyads.     

The NLM Evaluation Lecture Series: Introduction to the Special Section on Evaluating Health Communication Programs

This article introduces the Journal of Health Communication's special section, Evaluating Health Communication Programs. This special section is based on a public lecture series supported by the National Library of Medicine titled “Better Health: Evaluating Health Communication Programs” designed to share best practices for using evaluation research to develop, implement, refine, and institutionalize the best health communication programs for promoting public health. This introduction provides an overview to the series, summarizes the major presentations in the series, and describe implications from the series for translational health communication research, interventions, and programs that can enhance health outcomes.     

What every teacher needs to know about clinical reasoning

CONTEXT: One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. PURPOSE: The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. DISCUSSION: Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.     

Authenticity of instruction and student performance: a prospective randomised trial

Medical Education 2011: 45 : 807–817 Objectives This study aimed to investigate the relationship between the authenticity of instructional formats and outcome measures within a pre‐clerkship clinical reasoning course. Methods We conducted a randomised, prospective, crossover study with Year 2 medical students taking a pre‐clerkship clinical reasoning course. Students were randomised to small groups and exposed to three formats of differing instructional authenticity (paper case, DVD presentation, standardised patient [SP] presentation) across three subject areas (abdominal pain, anaemia, polyuria). Three student cohorts were taught using one instructional format per subject area so that each cohort received a different instructional format for each of the three subject areas. Outcome measures (objective structured clinical examination, video quiz, written examination) were selected to determine the effect of each instructional format on the clinical reasoning of students. Results Increasingly authentic instructional formats did not significantly improve clinical reasoning performance across all outcome measures and subject areas. However, the results of the video quiz showed significant differences in the anaemia subject area between students who had been instructed using the paper case and live SP‐based formats (scores of 47.4 and 57.6, respectively; p = 0.01) and in the abdominal pain subject area, in which students instructed using the DVD format scored higher than students instructed using either the paper case or SP‐based formats (scores of 41.6, 34.9 and 31.2, respectively; p = 0.002). Conclusions Increasing the authenticity of instructional formats does not appear to significantly improve clinical reasoning performance in a pre‐clerkship course. Medical educators should balance increases in authenticity with factors such as cognitive load, subject area and learner experience when designing new instructional formats.     

The structure of novice and expert occupational therapists' clinical reasoning before and after exposure to a domain-specific protocol

Background/aim:  The research aimed to determine the influence of a protocol designed for use in the domain of upper limb hypertonia due to brain injury on novice and expert occupational therapy clinical reasoning.
Method:  Individual, structured repertory grid interviews were completed with 13 novice and eight expert occupational therapists prior to, and following, exposure to a domain-specific clinical reasoning protocol. Data were subjected to quantitative analyses (Principal Components Analysis, Generalised Procrustes Analysis).
Results:  Novice participants demonstrated statistically significant change in the structure of their clinical reasoning following exposure to the protocol ( P  < 0.004). Prior to exposure, novices relied on therapy tasks, the problem-solving process, environmental factors and standard practice to structure their reasoning. Following exposure, novices' clinical reasoning changed to more closely reflect experts' reasoning. Thus, a 'structured approach' and (theoretical) practice perspectives became evident. Prior to exposure to the protocol, experts structured reasoning in terms of (personal and theoretical) practice perspectives, therapy tasks and the scope of such tasks (either 'general' or 'specific'). Following exposure, therapist/client collaboration and upper-limb-related constructs emerged as being used to structure experts' reasoning, although these changes were not statistically significant.
Conclusion:  A protocol designed for guiding clinical reasoning in the context of upper limb hypertonia was perceived to be conceptually useful by novice and expert occupational therapists.     

Uptake of a team briefing in the operating theatre: A Burkean dramatistic analysis

Communication among healthcare professionals is a focus for research and policy interventions designed to improve patient safety, but the challenges of changing interprofessional communication patterns are rarely described. We present an analysis of 756 preoperative briefings conducted by general surgery teams (anesthesiologists, nurses, and surgeons) at four urban Canadian hospitals in the context of two research studies conducted between August 2004 and December 2007. We ask the questions: how and why did briefings succeed, how and why did they fail, and what did they mean for different participants? Ethnographic fieldnotes documenting the coordination and performance of team briefings were analyzed using Kenneth Burke's concepts of motive and attitude. The language and behaviour of participants were interpreted as purposive and situated actions which reveal perceptions, beliefs and values. Motives and attitudes varied both within and across sites, professions, individuals, and briefings. They were contingent on the organizational, medical and social scenes in which the briefings took place and on participants' multiple perceived purposes for participating (protecting patient safety, exchanging information, engaging with the team, fulfilling professional commitments, participating in research, and meeting social expectations). Participants' attitudes reflected their recognition (or rejection) of specific purposes, the briefings' perceived effectiveness in serving these purposes, and the briefings' perceived alignment (or conflict) with other priorities. Our findings illustrate the intrinsically rhetorical and variable nature of change.