Abstract
Context specificity, or the variation in a participant’s performance from one case, or situation, to the next, is a recognized problem in medical education. However, studies have not explored the potential reasons for context specificity in experts using the lens of situated cognition and cognitive load theories (CLT). Using these theories, we explored the influence of selected contextual factors on clinical reasoning performance in internal medicine experts. We constructed and validated a series of videotapes portraying different chief complaints for three common diagnoses seen in internal medicine. Using the situated cognition framework, we modified selected contextual factors—patient, encounter, and/or physician—in each videotape. Following each videotape, participants completed a post-encounter form (PEF) and a think-aloud protocol. A survey estimating recent exposure from their practice to the correct videotape diagnoses was also completed. The time given to complete the PEF was randomly varied with each videotape. Qualitative utterances from the think-aloud procedure were converted to numeric measures of cognitive load. Survey and cognitive load measures were correlated with PEF performance. Pearson correlations were used to assess relations between the independent variables (cognitive load, survey of experience, contextual factors modified) and PEF performance. To further explore context specificity, analysis of covariance (ANCOVA) was used to assess differences in PEF scores, by diagnosis, after controlling for time. Low correlations between PEF sections, both across diagnoses and within each diagnosis, were observed (r values ranged from −.63 to .60). Limiting the time to complete the PEF impacted PEF performance (r = .2 to .4). Context specificity was further substantiated by demonstrating significant differences on most PEF section scores with a diagnosis (ANCOVA). Cognitive load measures were negatively correlated with PEF scores. The presence of selected contextual factors appeared to influence diagnostic more than therapeutic reasoning (r = − .2 to −.38). Contextual factors appear to impact expert physician performance. The impact observed is consistent with situated cognition and CLT’s predictions. These findings have potential implications for educational theory and clinical practice.
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References
Anderson, M. L. (2003). Embodied cognition: A field guide. Artificial Intelligence, 149, 91–130.
Baddeley, A. D. (1986). Working memory. Oxford: Clarendon.
Baddeley, A. D. (1992). Working Memory. Science, 255(5044), 556–559.
Bordage, G. (1994). Elaborated knowledge: a key to successful diagnostic thinking. Academic Medicine, 69, 883–885.
Bordage, G., & Lemieux, M. (1991). Semantic structures and diagnostic thinking of experts and novices. Academic Medicine, 65, S70–S72.
Clauser, B. E., Balog, K., Harik, P., Mee, J., & Kahramen, N. (2009). A multivariate generalizability analysis of history-taking and physical examination scores from the USMLE step 2 clinical skills examination. Academic Medicine, 84, S86–S89.
Durning, S. J., Artino, A. R., Pangaro, L. N., van der Vleuten, C., & Schuwirth, L. (2010a). Redefining context in the clinical encounter: Implications for research and training in medical education. Academic Medicine, 85, 894–901.
Durning, S. J., Artino, A. R., Boulet, J., LaRochelle, J., van der Vleuten, C. P. M., & Schuwirth, L. (2011a). The feasibility, reliability, and validity of a post-encounter form (PEF) for evaluating clinical reasoning. Medical Teacher (accepted).
Durning, S. J., Artino, A. R., Boulet, J., van der Vleuten, C. P. M., LaRochelle, J., Arze, B., et al. (2010b). Making use of contrasting participant views of the same encounter. Medical Education, 44, 953–961.
Durning, S. J., Artino, A. R., van der Vleuten, C. P. M., Pangaro, L., & Schuwirth, L. (2011b). Context and clinical reasoning: understanding the situation from the perspective of the expert’s voice. Medical Education (accepted).
Durning, S. J., LaRochelle, J., Pangaro, L. N., Artino, A. R., Boulet, J., van der Vleuten, C. P. M., & Schuwirth, L. (2011c). Does the authenticity of preclinical teaching format affect clinical clerkship outcomes: A prospective randomized crossover trial. Teaching and Learning in Medicine (in review).
Elstein, A. S., Shulman, L. S., & Sprafka, S. A. (1990). Medical problem solving: A ten-year retrospective study. Evaluation & the Health Professions, 13, 5–36.
Ericsson, K. A., Charness, N., Feltovich, P., & Hoffman, R. R. (Eds.). (2006). The Cambridge handbook of expertise and expert performance. New York, NY: Cambridge University Press.
Eva, K. W. (2011). On the relationship between problem-solving skills and professional practice. In Elaborating professionalism innovation and change in professional education (pp. 17–34). London: Springer.
Eva, K. A., Neville, A. J., & Norman, G. R. (1998). Exploring the etiology of content specificity: Factors influencing analogic transfer and problem solving. Academic Medicine, 73, S1–S5.
La Rochelle, J., Durning, S. J., Pangaro, L. N., Artino, A. R., Boulet, J., van der Vleuten, C. P. M., Schuwirth, L. (2011). The effect of increasing authenticity of instructional format on student performance: A prospective randomized trial. Medical Education (accepted).
Lindstom, A., Villing, J., Larsson, S., Seward, A., Aberg, N., & Holtelius, C. (2008). The effect of cognitive load on disfluencies during in-vehicle spoken dialogue. In Proceedings of interspeech.
Monajemi, A., Rikers, R. M. J. P., & Schmidt, H. G. (2007). Clinical case processing: A diagnostic versus a management focus. Medical Education, 41, 1166–1172.
Norman, G. R., Tugwell, P., Feightner, J. W., Muzzin, L. G., & Jacoby, L. L. (1995). Knowledge and clinical problem solving. Medical Education, 19, 344–356.
Paas, F., Renkl, A., & Sweller, J. (2003). Cognitive load theory and instructional design: Recent developments. Educational Psychologist, 38, 1–4.
Pangaro, L. (1999). A new vocabulary and other innovations for improving descriptive in-training evaluations. Academic Medicine, 74(11), 1203–1207.
Plass, J. L., Moreno, R., & Brunken, R. (2010). Cognitive load theory. New York, NY: Cambridge University Press.
van Merrienboer, J. J. G., & Sweller, J. (2005). Cognitive load theory and complex learning: Recent developments and future directions. Educational Psychology Review, 17, 147–177.
van Merrienboer, J. J. G., & Sweller, J. (2010). Cognitive load theory in health professional education: Design principles and strategies. Medical Education, 44, 85–93.
Villing, J. (2009). Dialogue behavior under high cognitive load. In Proceedings of SIGDIAL 2009: The 10th annual meeting of the special interest group in discourse and dialogue, pp. 322–325.
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Durning, S.J., Artino, A.R., Boulet, J.R. et al. The impact of selected contextual factors on experts’ clinical reasoning performance (does context impact clinical reasoning performance in experts?). Adv in Health Sci Educ 17, 65–79 (2012). https://doi.org/10.1007/s10459-011-9294-3
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DOI: https://doi.org/10.1007/s10459-011-9294-3