José F. Arocha

Medical expertise asa function of task difficulty

This paper is concerned with factors that disrupt the pattern of forward reasoning characteristic of experts with accurate performance. Two experiments are described. In the first, the performances of cardiologists, psychiatrists, and surgeons in diagnostic explanation of a clinical problem in cardiology were examined. In the second, the performances of cardiologists and endocrinologists in diagnostic explanation of clinical problems within and outside their domains of expertise were examined. The performances of researchers and practicing physicians are also compared. The results of Experiment 1 replicated earlier results regarding the relationship between forward reasoning and accurate diagnosis. There were no differences in recall as a function of expertise. Experts did not show any bias toward using specific knowledge from their own areas of expertise. The results of Experiment 2 showed that the breakdown of forward reasoning was related to the structure of the task. In particular, nonsalient cues induced some backward reasoning even in subjectswith accurate diagnoses. Some differences were also found between the types of explanation used by researchers and practitioners. The practitioners referred more to clinical components in their explanations, whereas the researchers focused more on the biomedical components.

A Primer on Aspects of Cognition for Medical Informatics

As a multidisciplinary field, medical informatics draws on a range of disciplines, such as computer science, information science, and the social and cognitive sciences. The cognitive sciences can provide important insights into the nature of the processes involved in human- computer interaction and help improve the design of medical information systems by providing insight into the roles that knowledge, memory, and strategies play in a variety of cognitive activities. In this paper, the authors survey literature on aspects of medical cognition and provide a set of claims that they consider to be important in medical informatics.

Cognitive psychological studies of representation and use of clinical practice guidelines

Clinical practice guidelines provide a means to enhance physician performance. This investigation was undertaken in an attempt to understand the nature of impact of guideline use on physician performance. We investigated the impact of (a) algorithmic-based and (b) text-based practice guidelines on clinical decision-making by physicians at varying levels of expertise. Data were collected using clinical scenarios and a think-aloud paradigm, both with (primed) and without (spontaneous) the use of the guidelines. The two guidelines used in the study were management of diabetes and screening for thyroid disease. The results show that guidelines were used as reminders for both experts and non-experts. Guidelines acted as an educational tool for non-experts by assisting in knowledge reorganization, particularly for the non-experts. Text and algorithmic guideline formats were both useful to physician performance depending on the purpose of use: solving clinical problems or learning. These results provide insights into how guidelines can be fine-tuned for different users and for different purposes. Empirical research, coupled with design principles from the cognitive sciences, can form an essential component of guideline design and development.

Methods of Cognitive Analysis to Support the Design and Evaluation of Biomedical Systems

This article provides a theoretical and methodological framework for the use of cognitive analysis to support the representation of biomedical knowledge and the design of clinical systems, using clinical-practice guidelines (CPGs) as an example. We propose that propositional and semantic analyses, when used as part of the system-development process, can improve the validity, usability, and comprehension of the resulting biomedical applications. The framework we propose is based on a large body of research on the study of how people mentally represent information and subsequently use it for problem solving. This research encompasses many areas of psychology, but the more important ones are the study of memory and the study of comprehension. Of particular relevance is research devoted to investigating the comprehension and memory of language, expressed verbally or in text. In addition, research on how contextual variables affect performance is informative because these psychological processes are influenced by situational variables (e.g., setting, culture). One important factor limiting the acceptance and use of clinical-practice guidelines (CPGs) may be the mismatch between a guidelines recommended actions and the physician-users mental models of what seems appropriate in a given case. Furthermore, CPGs can be semantically complex, often composed of elaborate collections of prescribed procedures with logical gaps or contradictions that can promote ambiguity and hence frustration on the part of those who attempt to use them. An improved understanding of the semantics and structure of CPGs may help to improve such matching, and ultimately the comprehensibility and usability of CPGs. Cognitive methods of analysis can help guideline designers and system builders throughout the development process, from the conceptual design of a computer-based system to its implementation phases. By studying how guideline creators and developers represent guidelines, both mentally and in text, and how end-users understand and make decisions with such guidelines, we can inform the development of technologies that seek to improve the match between the representations of experts and practitioners. We urge informaticians to recognize the potential relevance of cognitive analysis methods and to begin more extensive experimentation with the their use in biomedical informatics research.

Hypothesis Generation and the Coordination of Theory and Evidence in Novice Diagnostic Reasoning

This study investigates hypothesis generation and evaluation in clinical problem solving by medical trainees. The study focuses on 1) directionality of reasoning and 2) use of confir mation and disconfirmation strategies in generating and evaluating hypotheses. Two clinical problems were divided into segments of information containing presenting complaint, past history, and physical examination. The initial information indicated a typical myocardial infarct but subsequent information contradicted it. The results showed that the participating students predominantly used forward reasoning and confirmation strategies. When faced with con tradictory evidence: 1) second-year students ignored cues in the problem or reinterpreted them to fit the hypothesis; 2) third-year students generated concurrent hypotheses to account for different sets of data; and 3) fourth-year students generated several initial hypotheses and subsequently narrowed the hypothesis space by generating a single coherent diagnostic explanation. The results are discussed in terms of coordination of clinical evidence and its relationship to scientific reasoning. Key words: hypothesis generation; diagnostic reasoning; novice strategies; medical problem solving. (Med Decis Making 1993;13:198-211)

Steering through the murky waters of a scientific conflict: situated and symbolic models of clinical cognition

The situated action perspective, which embraces a diversity of views, challenges several of the fundamental assumptions of the symbolic information-processing framework underlying cognitive science and artificial intelligence. In this paper, we consider the following issues; symbolic representations, plans and actions, distributed cognition, and the transfer of learning. We evaluate each of these issues in terms of research and theories in clinical cognition and examine the implications for education and training, and for the integration of intelligent systems in medical practice. We argue for a reconceptualization of the symbolic framework in terms of the way the role of internal representations and cognitive activities are perceived. However, symbolic representations are integral to medical cognition and should continue to be central in any theoretical framework. A re-examination of cognitive science in medicine in terms of the relationship among physicians, technology, and the workplace could prove to be constructive in bridging the gap between theory and practice.

Evaluating evidence against diagnostic hypotheses in clinical decision making by students, residents and physicians

Clinicians are faced with the difficulty of filtering large quantities of information and incorporating evidence to make safe and accurate diagnostic, therapeutic and management decisions. One solution to this difficulty is the development of evidence-based decision support tools designed to provide relevant and up-to-date evidence to clinicians. However, as investigations of medical decision making have found that hypothesis generation and clinical reasoning differ as a function of expertise, the gathering, interpretation and use of evidence against hypotheses depends on the prior knowledge of the clinician. The specific focus of the study is to understand how clinical evidence is gathered and evaluated during diagnostic reasoning. Verbal data during clinical interactions with physicians, residents and final year medical students were collected and transcribed. The dialogues were analyzed using three levels of coding: cognitive, epistemological and linguistic pragmatic perspectives. Results show that: (a) the ability to index and use adequate evidence by physicians, residents and students is a function of the early generation of accurate hypotheses: and (b) strategies for resolving inconsistent evidence differ as a function of medical expertise. The relationship between these findings and its application for the development of adequate knowledge-based systems for indexing and retrieval is discussed.

Cognitive models in training health professionals to protect patients’ confidential information

Recent advances in theories of learning and knowledge acquisition in culturally-situated environments have illuminated the role of cognition in changing behavior, and in turn on influencing performance for the long term. One such advance focuses on the relationship between explicit formal training and implicit knowledge acquired through daily interactive activities in schools and organizations. The former relates more to instruction regarding the policy issues whereas the latter is tied closely to cultural, moral and organizational values. In this paper, we draw on these theories of cognition and learning to show the shift in thinking that is needed regarding education of health professionals, including steps required to assure that the protection of confidential information becomes part of their routine practices. Illustrative examples are used to show the nature of conceptual change in the health professionals knowledge organization and reasoning strategies that is necessary for more sustained behavior change with regards to protecting data confidentiality and privacy of individual patients. This re-conceptualization is intended to be reflected at various levels of training and education for health professionals, including influences on personal and organizational practices as well as revisions in medical-school and graduate-medical curricula.

Collaborative problem-solving in telemedicine and evidence interpretation in a complex clinical case

This study examined clinical problem-solving processes in the context of a telemedical consultation, in order to verify to what extent the technological environment preserves the characteristics of medical reasoning that are known to occur in more traditional clinical settings. This study also provided an opportunity for examining certain fundamental aspects of medical reasoning about complex cases. Within a case-study design, we used a theoretical framework and qualitative methods originating from cognitive science. Expert physicians used reasoning strategies commensurate with the complexity of the case. The technological context of the telemedical consultation did not overly contrive the interaction, allowing them to use real-time problem-solving processes characterizing medical reasoning in naturalistic settings. The results also suggest that high levels of expertise in the presence of very complex cases may elicit a particular configuration of problem-solving processes, associating certain reasoning patterns that are usually related to non-expert problem-solving with others that are typical of expertise. We believe that the evaluation of image transmission and diagnostic performance in telemedicine, as well as the determination of its indications and technological configurations, may benefit from taking into account, with the help of cognitive methodologies, the interacting problem-solving modalities that may be encountered in this context.

Cognitive assessment and health education in children from two different cultures

This paper presents research aimed at investigating high level comprehension and problem solving processes in children in two different countries, India and Colombia. To this end, we use a series of health-related cognitive tasks as assessment tools. In one study, we also examine childrens performance on these cognitive tasks, in relation to their nutritional status and parasitic load. The ages of the children tested ranged from 2 through 14 years. The tasks were designed to assess comprehension of sequences, organization of concepts, understanding of health routines (hygiene practices) and evaluation of hypothesis and evidence. The results show that children approach the different tasks with a baggage of beliefs and local knowledge of the world which determines their reasoning process, their comprehension and their problems solving. The results are discussed in terms of cognitive assessment approaches, as applied to classroom instruction. Given that children construct their understanding of reality based on what they already know and that education does not take this into account, we recommend that assessment tools should be devised that can tap prior knowledge and understanding, such that this can be analyzed and understood in relation to knowledge taught in the classroom. Current educational assessment fails in such an endeavor.