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Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians.

ABSTRACT: BACKGROUND: It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians. METHODS: We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-analyzed, following the Gale and Marsden model for clinical decision-making. Limited tests used to contrast data were t, chi2, and Fisher's. Scott's pi was used to determine inter-coder reliability. RESULTS: Fifteen dentists and 17 senior dental students participated in visits lasting 32.0 minutes (+/- 12.9) among experts, and 29.9 +/- 7.1 among students; contact time with patient was 26.4 +/- 13.9 minutes (experts), and 22.2 +/- 7.5 (students). The time elapsed between the first and the last instances of the clinician looking in the mouth was similar between experts and students. Ninety eight types of pieces of information were used in combinations with 12 DTPs. The main differences found in DTP utilization had dentists conducting diagnostic interpretations of findings with sufficient certainty to be considered definitive twice as often as students. Students resorted more often to more general or clarifying enquiry in their search for information than dentists. CONCLUSIONS: Differences in diagnostic strategies and concepts existed within clearly delimited types of cognitive processes; such processes were largely compatible with the analytic and (in particular) non-analytic approaches to clinical decision-making identified in the medical field. Because we were focused on a clinical presentation primarily made up of non-emergency treatment needs, use of other DTPs and concepts might occur when clinicians evaluate emergency treatment needs, complex rehabilitative cases, and/or medically compromised patients.

SUBMITTER: Maupome G

PROVIDER: S-EPMC2879228 | biostudies-literature | 2010

REPOSITORIES: biostudies-literature

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Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians.

Maupomé Gerardo G Schrader Stuart S Mannan Saurabh S Garetto Lawrence L Eggertsson Hafsteinn H

BMC oral health 20100513

<h4>Background</h4>It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians.<h4>Methods</h4>We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-an ...[more]

PMID: 20465826

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Project description:BackgroundShared decision making is a crucial component of evidence-based practice, but a lack of training in the "how to" of it is a major barrier to its uptake.ObjectiveTo evaluate the effectiveness of a brief intervention for facilitating shared decision making skills in clinicians and student clinicians.DesignMulti-centre randomized controlled trial.ParticipantsOne hundred and seven medical students, physiotherapy or occupational therapy students undertaking a compulsory course in evidence-based practice as part of their undergraduate or postgraduate degree from two Australian universities.InterventionThe 1-h small-group intervention consisted of facilitated critique of five-step framework, strategies, and pre-recorded modelled role-play. Both groups were provided with a chapter about shared decision making skills.Main measuresThe primary outcome was skills in shared decision making and communicating evidence [Observing Patient Involvement (OPTION) scale, items from the Assessing Communication about Evidence and Patient Preferences (ACEPP) Tool], rated by a blinded assessor from videorecorded role-plays.Secondary outcomesconfidence in these skills and attitudes towards patient-centred communication (Patient Practitioner Orientation Scale (PPOS)).Key resultsOf participants, 95 % (102) completed the primary outcome measures. Two weeks post-intervention, intervention group participants scored significantly higher on the OPTION scale (adjusted group difference?=?18.9, 95 % CI 12.4 to 25.4), ACEPP items (difference?=?0.9, 95 % CI 0.5 to 1.3), confidence measure (difference?=?13.1, 95 % CI 8.5 to 17.7), and the PPOS sharing subscale (difference?=?0.2, 95 % CI 0.1 to 0.5). There was no significant difference for the PPOS caring subscale.ConclusionsThis brief intervention was effective in improving student clinicians' ability, attitude towards, and confidence in shared decision making facilitation. Following further testing of the longer-term effects of this intervention, incorporation of this brief intervention into evidence-based practice courses and workshops should be considered, so that student clinicians graduate with these important skills, which are typically neglected in clinician training.

Project description:AimTo investigate primary care clinicians' views of a prototype locally relevant, real-time viral surveillance system to assist diagnostic decision-making and antibiotic prescribing for paediatric respiratory tract infections (RTI). Clinicians' perspectives on the content, anticipated use and impact were explored to inform intervention development.BackgroundChildren with RTIs are overprescribed antibiotics. Pressures on primary care and diagnostic uncertainty can lead to decisional biases towards prescribing. We hypothesise that real-time paediatric RTI surveillance data could reduce diagnostic uncertainty and help reduce unnecessary antibiotic prescribing.MethodologySemistructured one-to-one interviews with 21 clinicians from a range of urban general practitioner surgeries explored the clinical context and views of the prototype system. Transcripts were analysed using thematic analysis.ResultsThough clinicians self-identified as rational (not over)prescribers, cognitive biases influenced antibiotic prescribing decisions. Clinicians sought to avoid 'anticipated regret' around not prescribing for a child who then deteriorated. Clinicians were not aware of formal infection surveillance information sources (tending to assume many viruses are around), perceiving the information as novel and potentially useful. Perceptions of surveillance information as presented included: not relevant to decision-making/management; useful to confirm decisions post hoc; and increasing risks of missing sick children. Clinicians expressed wariness of using population-level data to influence individual patient decision-making and expressed preference for threat (high-risk) information identified by surveillance, rather than reassuring information about viral RTIs.ConclusionsMore work is needed to develop a surveillance intervention if it is to beneficially influence decision-making and antibiotic prescribing in primary care. Key challenges for developing interventions are how to address cognitive biases and how to communicate reassuring information to risk-oriented clinicians.

Project description:Background. Although effective interventions for shared decision making (SDM) exist, there is a lack of uptake of these tools into clinical practice. "Nudges," which draw on behavioral economics and target automatic thinking processes, are used by policy makers to influence population-level behavior change. Nudges have not been applied in the context of SDM interventions but have potential to influence clinician motivation, a primary barrier to long-term adoption of SDM tools. Objective. Describe, evaluate, and propose recommendations for the use of a behavioral economics framework (MINDSPACE) on clinician motivation and behavior during implementation of a validated decision aid (DA) for left ventricular assist device at nine hospitals. Methods. Qualitative thematic analysis of process notes from stakeholder meetings during the first 6 months of implementation to identify examples of how the MINDSPACE framework was operationalized. Quantitative implementation progress was evaluated using the RE-AIM framework. Results. MINDSPACE components were translated into concrete approaches that leveraged influential stakeholders, fostered ownership over the DA and positive emotional associations, spread desirable norms across sites, and situated the DA within established default processes. DA reach to eligible patients increased from 9.8% in the first month of implementation to 70.0% in the sixth month. Larger gains in reach were observed following meetings using MINDSPACE approaches. Limitations. The MINDSPACE framework does not capture all possible influences on behavior and responses to nudges may differ across populations. Conclusions. Behavioral economics can be applied to implementation science to foster uptake of SDM tools by increasing clinician motivation. Our recommendations can help other researchers effectively apply these approaches in real-world settings when there are often limited incentives and opportunities to change organizational- or structural-level factors.

Project description:BackgroundAppropriate tools are essential to support a clinician's decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population.ObjectiveTo examine the influence of the Ages and Stages Questionnaire-3rd edition (ASQ3) and the Bayley Scales of Infant Development-3rd edition (Bayley-III) scores within a clinically-based decision-making process.MethodsThis retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team's actual final integrated decisions (FID).ResultsComplete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians' and psychologists' TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions.ConclusionTaking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians' decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.

Dataset Information

Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians.

Publications

Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians.

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