Markus A. Feufel

Misleading communication of risk

Editors should enforce transparent reporting in abstracts

What do Web-Use Skill Differences Imply for Online Health Information Searches?

Background Online health information is of variable and often low scientific quality. In particular, elderly less-educated populations are said to struggle in accessing quality online information (digital divide). Little is known about (1) how their online behavior differs from that of younger, more-educated, and more-frequent Web users, and (2) how the older population may be supported in accessing good-quality online health information. Objective To specify the digital divide between skilled and less-skilled Web users, we assessed qualitative differences in technical skills, cognitive strategies, and attitudes toward online health information. Based on these findings, we identified educational and technological interventions to help Web users find and access good-quality online health information. Methods We asked 22 native German-speaking adults to search for health information online. The skilled cohort consisted of 10 participants who were younger than 30 years of age, had a higher level of education, and were more experienced using the Web than 12 participants in the less-skilled cohort, who were at least 50 years of age. We observed online health information searches to specify differences in technical skills and analyzed concurrent verbal protocols to identify health information seekers’ cognitive strategies and attitudes. Results Our main findings relate to (1) attitudes: health information seekers in both cohorts doubted the quality of information retrieved online; among poorly skilled seekers, this was mainly because they doubted their skills to navigate vast amounts of information; once a website was accessed, quality concerns disappeared in both cohorts, (2) technical skills: skilled Web users effectively filtered information according to search intentions and data sources; less-skilled users were easily distracted by unrelated information, and (3) cognitive strategies: skilled Web users searched to inform themselves; less-skilled users searched to confirm their health-related opinions such as “vaccinations are harmful.” Independent of Web-use skills, most participants stopped a search once they had found the first piece of evidence satisfying search intentions, rather than according to quality criteria. Conclusions Findings related to Web-use skills differences suggest two classes of interventions to facilitate access to good-quality online health information. Challenges related to findings (1) and (2) should be remedied by improving people’s basic Web-use skills. In particular, Web users should be taught how to avoid information overload by generating specific search terms and to avoid low-quality information by requesting results from trusted websites only. Problems related to finding (3) may be remedied by visually labeling search engine results according to quality criteria.

The impact of medical record technologies on collaboration in emergency medicine

PURPOSE Electronic medical records (EMR) promise potential benefits for the practice of medical care. However, individual technologies such as EMR must interact with the work system as a whole - including people, technology and work practices - to enable or hinder the coordination of dynamic work demands. Based on this extended perspective, we address in this paper how support technologies (should) impact the coordination of work across multiple agents, controlling a dynamic domain with multiple, interacting processes. The technology we address is the medical record and the dynamic domain is emergency medicine as it is practiced in the U.S. METHOD We performed 500 hours of naturalistic observations of physicians in two different hospital emergency departments in the Midwestern U.S differing in their reliance on paper or electronic medical records. RESULTS AND CONCLUSIONS An analysis of work practice across the two hospitals revealed the role of medical records in facilitating or hindering the coordination of time sensitive and context dependent distributed work, as well as the specific influence of EMR. Recognizing that work practice compensates for the limitations of technology, we suggest four requirements for the design of EMR to promote workplace efficiency: facilitation of locally customized data presentations; support for integration of hitherto fragmented record systems and data formats; support for effective multi-user coordination of control tasks; and guidance for standardizing a level of detail in planning and documenting care.

A field test of the effects of instruction design on colorectal cancer self-screening accuracy

A field experiment tested whether instruction design improves accurate adherence to instructions for medical do-it-yourself tests like the Fecal Occult Blood Test (FOBT). As part of an outreach campaign, 16,073 participants received FOBTs with instructions that were (i) human factored, (ii) motivational, (iii) human factored/motivational combined, or (iv) the standard used in the past. Among all test results returned (N = 2483), only the human factors instructions reduced errors in filling out result cards. However, after post-validating result cards that had errors, the human-factored, motivational and merged instructions reduced errors. The present findings show that medical instructions designed with human factors and persuasion principles increase accurate adherence. These design principles provide simple and cost-effective ways to increase test taking accuracy and FOBT effectiveness. Better screening instructions can improve the chances of detecting colorectal cancer early, which may help to decrease cancer mortality.

Calling 911: emergency medical services in need of human factors

Emergency medical services (EMS) play an important role in community health care systems. Paramedics provide basic life support, deliver babies, and transport critical patients to the hospital, among other services. We observed EMS units in action to learn about their underlying human factors/ergonomics (HF/E) and found that equipment and organizational systems were often difficult to use or poorly suited to task demands. Although HF/E professionals have the knowledge and tools to improve patient safety and occupational health, HF/E research on EMS is scarce. Our observations provide a systems overview pointing to needed improvements in equipment, decision making, and organizational coordination.

The Phenomenology of the Diagnostic Process: A Primary Care-Based Survey.

Background. While dichotomous tasks and related cognitive strategies have been extensively researched in cognitive psychology, little is known about how primary care practitioners (general practitioners [GPs]) approach ill-defined or polychotomous tasks and how valid or useful their strategies are. Objective. To investigate cognitive strategies used by GPs for making a diagnosis. Methods. In a cross-sectional study, we videotaped 282 consultations, irrespective of presenting complaint or final diagnosis. Reflective interviews were performed with GPs after each consultation. Recordings of consultations and GP interviews were transcribed verbatim and analyzed using a coding system that was based on published literature and systematically checked for reliability. Results. In total, 134 consultations included 163 diagnostic episodes. Inductive foraging (i.e., the initial, patient-guided search) could be identified in 91% of consultations. It contributed an average 31% of cues obtained by the GP in 1 consultation. Triggered routines and descriptive questions occurred in 38% and 84% of consultations, respectively. GPs resorted to hypothesis testing, the hallmark of the hypothetico-deductive method, in only 39% of consultations. Limitations. Video recordings and interviews presumably interfered with GPs’ behavior and accounts. GPs might have pursued more hypotheses and collected more information than usual. Conclusions. The testing of specific disease hypotheses seems to play a lesser role than previously thought. Our data from real consultations suggest that GPs organize their search for information in a skillfully adapted way. Inductive foraging, triggered routines, descriptive questions, and hypotheses testing are essential building blocks to make a diagnosis in the generalist setting.

Decisionmaking in practice: The dynamics of muddling through

An alternative to conventional models that treat decisions as open-loop independent choices is presented. The alterative model is based on observations of work situations such as healthcare, where decisionmaking is more typically a closed-loop, dynamic, problem-solving process. The article suggests five important distinctions between the processes assumed by conventional models and the reality of decisionmaking in practice. It is suggested that the logic of abduction in the form of an adaptive, muddling through process is more consistent with the realities of practice in domains such as healthcare. The practical implication is that the design goal should not be to improve consistency with normative models of rationality, but to tune the representations guiding the muddling process to increase functional perspicacity.

Promoting colorectal cancer screening in public health outreach campaigns

Objective: Research on public outreach campaigns is presented. Background: One study examines the effects of instruction design on adherence to cancer self-screening instructions. A second study examines the effect of persuasive announcements on increasing screening campaign participation. Method: The first study examined adherence to screening (operationalized as returning results for evaluation) given standard instructions, or one of three other versions: persuasive, human factored, or a combination of the two. The second study investigated combining persuasion with a campaign announcement to increase participation (operationalized as picking up a test kit). Results: The first study found that among first-time participants, the persuasive and human-factored instructions evoked higher result return rates than did the standard. The second study found that participation was significantly increased by adding persuasion to the campaign announcement. Conclusion: Enhancing motivation and reducing cognitive barriers increase adherence to test instructions and increase participation. Application: These are simple, cost-effective strategies that increase adherence to cancer screening in public outreach campaigns, which may reduce cancer-specific mortality.

Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

Tying up loose ends: a method for constructing and evaluating decision aids that meet blunt and sharp-end goals

We present a methodological framework for constructing and evaluating decision aids – fast and frugal trees (FFTs) – ideally suited to the front line of an organisation. Their performance can be analysed in signal detection theory, allowing for transparent selection of FFTs given managerial-level trade-offs among type I and II errors. We extend FFTs from binary classification to selection from multiple actions (FFT multiple) as well as performance analysis to organisational goal states beyond type I and II error reduction. Concepts and framework are introduced and a tutorial-style example application (threat assessment at military checkpoints) is provided. Throughout, we discuss ways to deal with missing or incomplete data and show that the performance of decision aids may be overestimated if the effectiveness of actions is not heeded. The methodology can be used to construct and evaluate decision aids in any area characterised by dichotomised cues and a one-to-many mapping between categorisation outcomes and actions. Practitioner Summary: The paper presents a methodological framework for the construction of decision aids and their evaluation along multiple goal states across institutional levels. We then apply this framework to construct and evaluate decision aids for threat assessment in military operations. Ways to deal with missing and incomplete data are discussed.