Meredith Young

Non-analytical models of clinical reasoning: the role of experience

Objective  This paper aims to summarise the evidence supporting the role of experience‐based, non‐analytic reasoning (NAR) or pattern recognition as a central feature of expert medical diagnosis.

Use of relative and absolute effect measures in reporting health inequalities: structured review

Objective To examine the frequency of reporting of absolute and relative effect measures in health inequalities research. Design Structured review of selected general medical and public health journals. Data sources 344 articles published during 2009 in American Journal of Epidemiology, American Journal of Public Health, BMJ, Epidemiology, International Journal of Epidemiology, JAMA, Journal of Epidemiology and Community Health, The Lancet, The New England Journal of Medicine, and Social Science and Medicine. Main outcome measures Frequency and proportion of studies reporting absolute effect measures, relative effect measures, or both in abstract and full text; availability of absolute risks in studies reporting only relative effect measures. Results 40% (138/344) of articles reported a measure of effect in the abstract; among these, 88% (122/138) reported only a relative measure, 9% (13/138) reported only an absolute measure, and 2% (3/138) reported both. 75% (258/344) of all articles reported only relative measures in the full text; among these, 46% (119/258) contained no information on absolute baseline risks that would facilitate calculation of absolute effect measures. 18% (61/344) of all articles reported only absolute measures in the full text, and 7% (25/344) reported both absolute and relative measures. These results were consistent across journals, exposures, and outcomes. Conclusions Health inequalities are most commonly reported using only relative measures of effect, which may influence readers’ judgments of the magnitude, direction, significance, and implications of reported health inequalities.

Medicine in the Popular Press: The Influence of the Media on Perceptions of Disease

In an age of increasing globalization and discussion of the possibility of global pandemics, increasing rates of reporting of these events may influence public perception of risk. The present studies investigate the impact of high levels of media reporting on the perceptions of disease. Undergraduate psychology and medical students were asked to rate the severity, future prevalence and disease status of both frequently reported diseases (e.g. avian flu) and infrequently reported diseases (e.g. yellow fever). Participants considered diseases that occur frequently in the media to be more serious, and have higher disease status than those that infrequently occur in the media, even when the low media frequency conditions were considered objectively ‘worse’ by a separate group of participants. Estimates of severity also positively correlated with popular print media frequency in both student populations. However, we also see that the concurrent presentation of objective information about the diseases can mitigate this effect. It is clear from these data that the media can bias our perceptions of disease.

The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning.

Purpose Diagnostic errors are thought to arise from cognitive biases associated with System 1 reasoning, which is rapid and unconscious. The primary hypothesis of this study was that the instruction to be slow and thorough will have no advantage in diagnostic accuracy over the instruction to proceed rapidly. Method Participants were second-year residents who volunteered after they had taken the Medical Council of Canada (MCC) Qualifying Examination Part II. Participants were tested at three Canadian medical schools (McMaster, Ottawa, and McGill) in 2010 (n = 96) and 2011 (n = 108). The intervention consisted of 20 computer-based internal medicine cases, with instructions either (1) to be as quick as possible but not make mistakes (the Speed cohort, 2010), or (2) to be careful, thorough, and reflective (the Reflect cohort, 2011). The authors examined accuracy scores on the 20 cases, time taken to diagnose cases, and MCC examination performance. Results Overall accuracy in the Speed condition was 44.5%, and in the Reflect condition was 45.0%; this was not significant. The Speed cohort took an average of 69 seconds per case versus 89 seconds for the Reflect cohort (P < .001). In both cohorts, cases diagnosed incorrectly took an average of 17 seconds longer than cases diagnosed correctly. Diagnostic accuracy was moderately correlated with performance on both written and problem-solving components of the MCC licensure examination and inversely correlated with time. Conclusions The study demonstrates that simply encouraging slowing down and increasing attention to analytical thinking is insufficient to increase diagnostic accuracy.

The relationship between response time and diagnostic accuracy

Purpose Psychologists theorize that cognitive reasoning involves two distinct processes: System 1, which is rapid, unconscious, and contextual, and System 2, which is slow, logical, and rational. According to the literature, diagnostic errors arise primarily from System 1 reasoning, and therefore they are associated with rapid diagnosis. This study tested whether accuracy is associated with shorter or longer times to diagnosis. Method Immediately after the 2010 administration of the Medical Council of Canada Qualifying Examination (MCCQE) Part II at three test centers, the authors recruited participants, who read and diagnosed a series of 25 written cases of varying difficulty. The authors computed accuracy and response time (RT) for each case. Results Seventy-five Canadian medical graduates (of 95 potential participants) participated. The overall correlation between RT and accuracy was −0.54; accuracy, then, was strongly associated with more rapid RT. This negative relationship with RT held for 23 of 25 cases individually and overall when the authors controlled for participants’ knowledge, as judged by their MCCQE Part I and II scores. For 19 of 25 cases, accuracy on each case was positively related to experience with that specific diagnosis. A participant’s performance on the test overall was significantly correlated with his or her performance on both the MCCQE Part I and II. Conclusions These results are inconsistent with clinical reasoning models that presume that System 1 reasoning is necessarily more error prone than System 2. These results suggest instead that rapid diagnosis is accurate and relates to other measures of competence.

Food for thought. What you eat depends on your sex and eating companions

In a naturalistic study, we investigated the influence of gender, group size and gender composition of groups of eaters on food selected for lunch and dinner (converted to total calories per meal) of 469 individuals (198 groups) in three large university cafeterias. In dyads, women observed eating with a male companion chose foods of significantly lower caloric value than those observed eating with another woman. Overall, group size was not a significant predictor of calories, but womens calories were negatively predicted by numbers of men in the group, while the numbers of women in the group had a marginally significant positive impact on calorie estimates. Mens calorie totals were not affected by total numbers of men or women. This study supports previous investigations, but is unique in making naturalistic observations.

A comprehensive checklist for reporting the use of OSCEs.

Background: The Objective Structured Clinical Examination (OSCE) has experienced an explosion of use which has rarely been accompanied by systematic investigations on its validity, reliability and feasibility. A systematic review of OSCE was undertaken as part of Best Evidence Medical Education at the Centre for Evidence Based Medicine of the Faculty of Medicine of the University of Lisbon. Several problems were identified with published papers relating to completeness of information presented, methodological issues or the use of terminology. Aim: To identify a need for standardization within the reporting of OSCE studies in medical education based in the first 104 papers of the aforementioned review. Method: Two independent reviewers coded each paper. Results: The most important problem identified was the lack of information, followed by the degree of inconsistency when reporting on OSCEs (papers with missing data and papers where data was given in a way that interpretation is difficult or impossible in terms of evidence; heterogeneity in reporting, lack of a standardized vocabulary, statistical errors and lack of structure within reporting). Conclusions: The authors present a ‘Comprehensive Checklist for those describing the use of OSCEs in the report of educational literature’ as an attempt to encourage better report standards.

Calling for a broader conceptualization of diversity: surface and deep diversity in four Canadian medical schools.

Purpose Policy groups recommend monitoring and supporting more diversity among medical students and the medical workforce. In Canada, few data are available regarding the diversity of medical students, which poses challenges for policy development and evaluation. The authors examine diversity through a framework of surface (visible) and deep (less visible) dimensions and present data regarding a sample of Canadian medical students. Method Between 2009 and 2011, nine cohorts from four Canadian medical schools completed the Health Professions Student Diversity Survey (HPSDS) either on paper or online. Items asked each participant’s age, gender, gender identity, sexual identity, marital status, ethnicity, rural status, parental income, and disability. Data were analyzed descriptively and compared, when available, with national data. Results Of 1,892 students invited, 1,552 (82.0%) completed the HPSDS. Students tended to be 21 to 25 years old (68.3%; 1,048/1,534), female (59.0%; 902/1,529), heterosexual (94.6%; 1,422/1,503), single (90.1%; 1,369/1,520), and unlikely to report any disability (96.5%; 1,463/1,516). The majority of students identified with the gender on their birth certificate (99.8%; 1,512/1,515). About half had spent the majority of their lives in urban environments (46.7%; 711/1,521), and most reported parental household incomes of over

Residents as role models: impact on undergraduate trainees.

100,000/year (57.6%; 791/1,373). Overall, they were overrepresentative of higher-income groups and underrepresentative of populations of Aboriginal, black, or Filipino ethnicities in Canada. Conclusions The authors propose the development of a National Student Diversity Database to support both locally relevant policies regarding pipeline programs and an examination of current application and selection procedures to identify potential barriers for underrepresented students.

Mapping as a learning strategy in health professions education: a critical analysis

Purpose Although researchers have investigated the value of physician role models, residents as role models have received less attention. The objectives of this study were to (1) investigate the importance of resident role models in the education and career choices of medical students, (2) examine the types of factors students judge to be most important in selecting resident role models, and (3) evaluate the specific attributes (within each factor type) that students perceive to be most important, comparing these attributes with those previously published on physician role models. Method This was a cross-sectional, survey-based study, conducted in 2011, in which graduating medical students at McGill University completed a questionnaire on their perceptions of resident role models. The authors analyzed data using descriptive statistics and, for items with scalar responses, repeated measures analysis of variance. Results Of 165 possible student respondents, 151 (92%) completed the questionnaire. The findings suggest that (1) resident role models play an important role in both the education and career choice of medical students, (2) resident and attending staff role models are equally important to the education of medical students, although attending staff role models appear to be more important for students’ career choices, and (3) the factors and specific attributes important in selecting resident role models align with those in previously published literature on physician role models. Conclusions This study, suggesting that resident and attending physician role models are equally important to undergraduate education, highlights the importance of supporting residents in their status as role models.