This module will guide you in how to use the Assessment of Reasoning tool to assess a learner's ability to think about his or her diagnostic thinking process. Heuristics and biases describe tendencies in human thinking. These tendencies allow for efficient and often successful decision-making, but they can also lead to diagnostic error.
The ability to think about one's own thinking can help recognize these tendencies. This is called metacognition. One of the common tendencies in our thinking is called anchoring.
This is when a clinician fixates on a specific feature or finding early in the diagnostic process and ignores subsequent contradictory clinical information. In this example of anchoring, the clinician considers peptic ulcer disease early when evaluating epigastric pain, but does not stop to consider coronary artery disease when the patient describes the epigastric pain getting worse with exercise. fatigue and stress can also affect the quality of our diagnostic thinking.
For example, clinicians may make low-quality decisions if they are sleep-deprived, distracted, or under stress. Let's look at a case now to show you how to use the ART to assess a learner's ability to analyze their own thinking during the diagnostic process. Ms. Laura Thomas, a 27-year-old woman, presents with a three-day history of fatigue, sore throat, nasal congestion, and clear redness.
rhinorrhea without fever or headache. The family medicine resident knows the patient well, having helped her through a difficult pregnancy and delivered her baby eight months ago. Ms. Thomas requests an antibiotic prescription which she believes has helped her in the past. The resident diagnoses acute bacterial sinusitis and prescribes antibiotics.
Analyzing or thinking about one's own thinking or metacognition is not a standard part of the case presentation. In order to solicit an observable behavior from learners, a supervising clinician should ask learners if they can think of any situational or emotional factors that could be influencing his or her diagnostic thinking. This is an example of a high performer responding to your question about metacognition, whom you would mark as complete on the ART.
If I think more about it, I'm remembering how much I bonded with this patient over her delivery and recognize that I am the one who is the most important person in the world. I don't want to introduce conflict. I'm realizing now that when I have a personal connection, I have to be particularly vigilant about my decision-making process. If the learner is unaware of how such factors may have influenced their thinking, you would mark minimal on the ART. The supervising clinician could facilitate metacognition by asking the learner to think of how she would have diagnosed and treated the patient under different circumstances.
For example, if it were a new patient, to her or if the patient did not request antibiotics. This type of questioning may help the learner isolate the clinical data from the emotional factors that led to the misdiagnosis of bacterial sinusitis and may help the learner develop their metacognitive ability for future cases. In summary, a clinician's diagnostic thinking may be influenced by cognitive tendencies and many situational and emotional factors. The ability to think about one's own diet diagnostic thinking can help clinicians recognize these tendencies and may provide an opportunity to improve decision making.