Context and clinical reasoning
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Date
2018-04-27Author
McBee, Elexis
Ratcliffe, Temple
Schuwirth, Lambert W T
O'Neill, Daniel
Meyer, Holly
Madden, Shelby J
Durning, Steven J
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Introduction Studies have shown that a physician’s clinical reasoning performance can be influenced by contextual
factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in
order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the theoretical
framework, our aim was to evaluate the verbalized clinical reasoning processes of medical students in order to describe
what impact the presence of contextual factors has on their reasoning performance.
Methods Seventeen medical student participants viewed three video recordings of clinical encounters portraying straightforward
diagnostic cases in internal medicine with explicit contextual factors inserted. Participants completed a computerized
post-encounter form as well as a think-aloud protocol. Three authors analyzed verbatim transcripts from the
think-aloud protocols using a constant comparative approach. After iterative coding, utterances were analyzed and grouped
into categories and themes.
Results Six categories and ten associated themes emerged, which demonstrated overlap with findings from previous studies
in resident and attending physicians. Four overlapping categories included emotional disturbances, behavioural inferences
about the patient, doctor-patient relationship, and difficulty with closure. Two new categories emerged to include anchoring
and misinterpretation of data.
Discussion The presence of contextual factors appeared to impact clinical reasoning performance in medical students. The
data suggest that a contextual factor can be innate to the clinical scenario, consistent with situated cognition theory. These
findings build upon our understanding of clinical reasoning performance from both a theoretical and practical perspective.
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Open Access
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