Farrell J. Lloyd

Physician decision making and cardiac risk: Effects of knowledge, risk perception, risk tolerance, and fuzzy processing

Despite training, professionals sometimes make serious errors in risky decision making. The authors investigated judgments and decisions for 9 hypothetical patients at 3 levels of cardiac risk, comparing student and physician groups varying in domain-specific knowledge. Decisions were examined regarding whether they deviated from guidelines, how risk perceptions and risk tolerances determined decisions, and how the latter differed for knowledge groups. More knowledgeable professionals were better at discriminating levels of risk according to external correspondence criteria but committed similar errors in disjunctive probability judgments, violating internal coherence criteria. Also, higher knowledge groups relied on fewer dimensions of information than did lower knowledge groups. Consistent with fuzzy-trace theory, experts achieved better discrimination by processing less information and made sharper all-or-none distinctions among decision categories.

Theories of false memory in children and adults.

Abstract Much attention has recently been paid to false-memory effects in children and adults. Attention initially focused on the effects themselves. Most observers now agree that false-memory effects are robust and replicable, although they are subject to constraints (e.g., Lindsay 1990; Reyna & Titcomb 1997; Zaragoza & Lane 1994; Zaragoza, Lane, Ackil & Chambers 1997). Using noncoercive procedures, it is possible to induce people to falsely remember witnessing events that they never experienced (e.g., that they saw a yield sign, rather than a stop sign; Loftus 1979; Loftus, Miller & Burns 1978). Currently, researchers are beginning to examine the origins of such effects: How are false memories created, and what can be done to minimize them? It has become apparent that the key questions of prediction and prevention must be addressed through theory development, i.e., by deepening our understanding of false-memory phenomena. In this article, we explore contemporary explanations for false-memory effects in children and adults, including constructivism, source monitoring, and fuzzy-trace theory. Our discussion is divided into four sections. In the first section, we briefly review the assumptions underlying different theoretical approaches. In the second section, various false-memory effects are described, and their interactions with age, delay, and type of questioning. Laboratory demonstrations of false memories are supplemented by real-life examples from clinical medicine. Then, we examine how each of these effects is explained from different theoretical perspectives. Finally, we take stock of the available evidence favoring different explanations for false-memory effects, and discuss the implications of that evidence for subsequent theorizing and for improving memory performance.

A Web exercise in evidence-based medicine using cognitive theory

Our aim was to improve clinical reasoning skills by applying an established theory of memory, cognition, and decision making (fuzzy-trace theory) to instruction in evidence-based medicine. Decision-making tasks concerning chest pain evaluation in women were developed for medical students and internal medicine residents. The fuzzy-trace theory guided the selection of online sources (e.g., target articles) and decision-making tasks. Twelve students and 22 internal medicine residents attended didactic conferences emphasizing search, evaluation, and clinical application of relevant evidence. A 17-item Likert scale questionnaire assessed participants’ evaluation of the instruction. Ratings for each of the 17 items differed significantly from chance in favor of this alternative approach to instruction. We conclude that fuzzy-trace theory may be a useful guide for developing learning exercises in evidence-based medicine.

Clinical Gist and Medical Education: Connecting the Dots

THERE IS LITTLE EVIDENCE THAT CONTINUING MEDIcal education improves practicing physicians’ clinical reasoning and the quality of care. The central roles of medical education include helping clinicians assimilate new knowledge and assessing clinicians’ performance. Although electronic sources can deliver information quickly, human cognitive processes do not allow clinicians to encode all the information into memory promptly and predictably at the point of care (including approximately 1500 articles indexed daily by the National Library of Medicine). When learning new information, humans rely on 2 types of memory: verbatim and gist. Verbatim representations capture the literal facts or “surface form” of information (eg, that a cardiac syndrome is called Takotsubo cardiomyopathy), whereas gist representations capture its meaning or interpretation (eg, that the syndrome may be elicited by stress in the absence of coronary artery disease). An illustration of the difference between verbatim and gist memory is found in a comparison of the oral presentation of a medical student with that of an experienced clinician. The student presents the patient’s symptoms as a list of unconnected facts (eg, fever, cirrhosis, positive blood cultures, ascites, pneumonia, peritonitis, and urinary tract infection). The clinician’s discussion is meaningfully connected: a patient is immunocompromised from cirrhosis, which leads to enterococcal bacteremia with seeding of various sites and a concern about endocarditis. Clinical reasoning (the process of medical decision making) is clearly superior if the gist of patient symptoms can be recognized. Experienced physicians tend to rely on such gist-based reasoning. Verbatim and gist mental representations are key elements of a framework of memory and cognition called fuzzytrace theory. This is termed a dual process theory because it describes how verbatim and gist representations of information are encoded into memory separately and how each forms the basis of clinical reasoning. This framework describes and predicts many clinical observations important to medical educators, such as lack of significant clinical influence from guidelines, calculators, and continuing medical education. Gist memory has implications for medical education with respect to (1) the goals of instruction, (2) assessment, and (3) the type of education provided at the point of care. One of the goals of instruction is to ensure that learners remember not only verbatim detail but that they also retain the core gist of information. Although it may be assumed that physicians who can recall vast stores of knowledge in precise detail have mastered learned material, this has been disproved by research showing that the accuracy of verbatim memories has no bearing on the accuracy of gist memories. Because diagnostic expertise is content-specific, most physicians have gaps in both types of memory and educational methods should provide support for both. Inculcating gist memories requires a different process of instruction compared with rote recall, emphasizing far transfer (the ability to solve new problems that are not superficially similar to old problems). Methods used in medical education to achieve far transfer include presenting diverse examples that differ superficially from one another during training to help learners extract the underlying commonalities across cases. For instance, an elderly woman develops chest pain during her husband’s funeral. The emergency medicine resident orders an electrocardiogram (ECG) that indicates ischemia and cardiac markers that reveal an elevated troponin T level. The patient undergoes emergency cardiac catheterization, which reveals normal coronary arteries and a reduced left ventricular ejection fraction. Apical-ballooning syndrome, which the resident learns is also known as brokenheart syndrome and Takotsubo cardiomyopathy, is diagnosed. Later, the same resident sees a woman with diabetes and a history of heart disease, chest pain, an abnormal ECG, and elevated troponin T, who has an abnormal coronary catheterization. The resident creates a gist memory of the key difference between Takotsubo cardiomyopathy and acute coronary syndrome, specifically, that the origin of Takotsubo cardiomyopathy is not coronary artery disease. Helping learners extract gist has the advantages that gist memories endure over time and are more robust to interference from distractions such as stress and emotion.

A comprehensive information technology system to support physician learning at the point of care.

MayoExpert is a multifaceted information system integrated with the electronic medical record (EMR) across Mayo Clinic’s multisite health system. It was developed as a technology-based solution to manage information, standardize clinical practice, and promote and document learning in clinical contexts. Features include urgent test result notifications; models illustrating expert-approved care processes; concise, expert-approved answers to frequently asked questions (FAQs); a directory of topic-specific experts; and a portfolio for provider licensure and credentialing. The authors evaluate MayoExpert’s reach, effectiveness, adoption, implementation, and maintenance. Evaluation data sources included usage statistics, user surveys, and pilot studies. As of October 2013, MayoExpert was available at 94 clinical sites in 12 states and contained 1,368 clinical topics, answers to 7,640 FAQs, and 92 care process models. In 2012, MayoExpert was accessed at least once by 2,578/3,643 (71%) staff physicians, 900/1,374 (66%) midlevel providers, and 1,728/2,291 (75%) residents and fellows. In a 2013 survey of MayoExpert users with 536 respondents, all features were highly rated (≥ 67% favorable). More providers reported using MayoExpert to answer questions before/after than during patient visits (68% versus 36%). During November 2012 to April 2013, MayoExpert sent 1,660 notifications of new-onset atrial fibrillation and 1,590 notifications of prolonged QT. MayoExpert has become part of routine clinical and educational operations, and its care process models now define Mayo Clinic best practices. MayoExpert’s infrastructure and content will continue to expand with improved templates and content organization, new care process models, additional notifications, better EMR integration, and improved support for credentialing activities.

Meningeal Coccidioidomycosis Diagnosed by Real-Time Polymerase Chain Reaction Analysis of Cerebrospinal Fluid

We describe two cases of coccidioidal meningitis (CM) diagnosed using real-time polymerase chain reaction (PCR) analysis of cerebrospinal fluid. These cases highlight the promise of PCR as a diagnostic method to assist in the rapid diagnosis of CM.

An Automated Clinical Alert System for Newly-Diagnosed Atrial Fibrillation

Objective Clinical decision support systems that notify providers of abnormal test results have produced mixed results. We sought to develop, implement, and evaluate the impact of a computer-based clinical alert system intended to improve atrial fibrillation stroke prophylaxis, and identify reasons providers do not implement a guideline-concordant response. Materials and Methods We conducted a cohort study with historical controls among patients at a tertiary care hospital. We developed a decision rule to identify newly-diagnosed atrial fibrillation, automatically notify providers, and direct them to online evidence-based management guidelines. We tracked all notifications from December 2009 to February 2010 (notification period) and applied the same decision rule to all patients from December 2008 to February 2009 (control period). Primary outcomes were accuracy of notification (confirmed through chart review) and prescription of warfarin within 30 days. Results During the notification period 604 notifications were triggered, of which 268 (44%) were confirmed as newly-diagnosed atrial fibrillation. The notifications not confirmed as newly-diagnosed involved patients with no recent electrocardiogram at our institution. Thirty-four of 125 high-risk patients (27%) received warfarin in the notification period, compared with 34 of 94 (36%) in the control period (odds ratio, 0.66 [95% CI, 0.37–1.17]; p = 0.16). Common reasons to not prescribe warfarin (identified from chart review of 151 patients) included upcoming surgical procedure, choice to use aspirin, and discrepancy between clinical notes and the medication record. Conclusions An automated system to identify newly-diagnosed atrial fibrillation, notify providers, and encourage access to management guidelines did not change provider behaviors.

Speed and accuracy of a point of care web-based knowledge resource for clinicians: a controlled crossover trial.

Background Effective knowledge translation at the point of care requires that clinicians quickly find correct answers to clinical questions, and that they have appropriate confidence in their answers. Web-based knowledge resources can facilitate this process. Objective The objective of our study was to evaluate a novel Web-based knowledge resource in comparison with other available Web-based resources, using outcomes of accuracy, time, and confidence. Methods We conducted a controlled, crossover trial involving 59 practicing clinicians. Each participant answered questions related to two clinical scenarios. For one scenario, participants used a locally developed Web-based resource, and for the second scenario, they used other self-selected Web-based resources. The local knowledge resource (“AskMayoExpert”) was designed to provide very concise evidence-based answers to commonly asked clinical questions. Outcomes included time to a correct response with at least 80% confidence (primary outcome), accuracy, time, and confidence. Results Answers were more often accurate when using the local resource than when using other Web-based resources, with odds ratio 6.2 (95% CI 2.6-14.5; P<.001) when averaged across scenarios. Time to find an answer was faster, and confidence in that answer was consistently higher, for the local resource (P<.001). Overconfidence was also less frequent with the local resource. In a time-to-event analysis, the chance of responding correctly with at least 80% confidence was 2.5 times greater when using the local resource than with other resources (95% CI 1.6-3.8; P<.001). Conclusions Clinicians using a Web-based knowledge resource designed to provide quick, concise answers at the point of care found answers with greater accuracy and confidence than when using other self-selected Web-based resources. Further study to improve the design and implementation of knowledge resources may improve point of care learning.

The Psychology of Human-Computer Mismatches

Publisher Summary This chapter proposes a framework for the assessment of learning outcomes associated with technology. It discusses the kind of expertise that is required for such assessment, the nature of current instructional technologies, and potential mismatches between technologies and human learning. These mismatches occur with respect to four classes of characteristics of human learners: natural learning and memory processes; perception; individual differences in learning styles and other cognitive factors; and individual differences in social and personality factors. The human–machine mismatches occur in each of these domains. The chapter determines the instructional outcomes produced by learning technologies. Educational uses of technology suggest several conclusions that should inform a research agenda. Four options predominate university courses: Web-based instruction, video-delivered distance learning, electronic interactive-learning environments, and simulated environments. Technology-infused instruction poses some fundamental dilemmas for learners that are rooted in mismatches between the capabilities of humans and those of machines.

Clinical study of an online tool for standardizing hospital care

Abstract:We assessed if use of an online clinical decision support tool improved standardization and quality of care in hospitalized patients with lower extremity cellulitis (LEC). This was a 14-month preintervention and postintervention study of 85 LEC admissions. There was significantly higher usage of the online LEC care process model (CPM) in the postintervention phase (p < .001). There was a trend toward higher rates of appropriate antibiotic regimen in the postintervention group both initially and at discharge (p = .063 for both). A sensitivity analysis of CPM users versus nonusers demonstrated a significantly higher rate of appropriate initial antibiotics prescribed when the CPM was used (p < .001). Use of this online CPM was associated with improved standardization, as demonstrated by increased ordering of an appropriate initial antibiotic regimen for hospitalized patients with LEC.