Fig. 1
Situated cognition and clinical reasoning—a theoretical framework. The clinical outcome is dependent on the interplay between the patient, the environment, and the clinician. The circles show the relationship between all individual factors, while the centre portion represents the clinical outcome (clinical reasoning) being affected by all three. Situated cognition suggests that the individual and their environment can influence an outcome. In the case of a clinical environment, the outcome would involve the patient. (Note: the diagram simplifies the numerous interactions that can occur between the various factors within and between the various circles)
Table 1
Video recorded clinical encounters with modified contextual factors used to evaluate clinical reasoning in medical students
|
Clinical encounter |
Diagnosis |
Contextual factor/s modified |
|---|---|---|
|
Case One |
HIV |
English as a second language |
|
Case Two |
Colorectal cancer |
Emotional volatility (Challenging of the physician’s credentials) |
|
Case Three |
Diabetes mellitus |
English as a second language + emotional volatility |
Table 2
Categories and themes identified from think-aloud transcripts of medical students (Multiple constructs emerged from the data that appeared to be the consequence of contextual factors during the clinical encounter. These were grouped into six categories with associated themes.)
|
Categories |
Themes |
Example quote |
|---|---|---|
|
Emotional reactions by the student |
Emotional reactions to contextual factors |
‘Her lack of eye contact in this interview is disturbing to me.’ |
|
Behavioural inferences about the patient |
Behavioural inferences made in response to contextual factors |
‘She sounds lonely.’ |
|
Doctor-patient relationship |
Identifying that the contextual factor may hinder the doctor patient relationship |
‘She is still frustrated so he (the doctor) probably needs to address that.’ |
|
Difficulty with closure |
Need for additional history and physical exam information |
‘How much exercise does she do? Tired? What does that mean?’ |
|
Inability to utilize presented information |
‘What is that spot on her leg?’ | |
|
Presence of uncertainty of clinical reasoning |
‘So my diagnosis would probably be infectious aetiology.’ | |
|
Anchoring |
Displayed tendency to anchor on first diagnosis |
‘So four years is a long time ago (prior head injury), but either way diabetes insipidus is what I’m thinking for my lead diagnosis.’ |
|
Limited differential diagnosis |
– | |
|
Misinterpretation of data |
Factual errors |
‘Lack of insulin means she probably can’t digest her food. Keeps you hungry.’ |
|
Limitations in knowledge |
‘I don’t know anything about feminine care so refer her to OB/GYN.’ |