title: Consequences of contextual factors on clinical reasoning in resident physicians.
abstract: Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think-aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. This finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.
authors.affiliation: Department of Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA. elexis.c.mcbee@gmail.com.
authors.forename: Elexis
authors.initials: E
authors.lastname: McBee
authors.affiliation: Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
authors.forename: Temple
authors.initials: T
authors.lastname: Ratcliffe
authors.affiliation: Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD, 20814, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Picho
authors.affiliation: Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD, 20814, USA.
authors.forename: Anthony R
authors.initials: AR
authors.lastname: Artino
authors.affiliation: Flinders University, School of Medicine, GPO Box 2100, Adelaide, 5001, South Australia.
authors.forename: Lambert
authors.initials: L
authors.lastname: Schuwirth
authors.affiliation: Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD, 20814, USA.
authors.forename: William
authors.initials: W
authors.lastname: Kelly
authors.affiliation: Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD, 20889, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Masel
authors.affiliation: Department of Educational Development and Research, Maastricht University, 6200 MD, Maastricht, The Netherlands.
authors.forename: Cees
authors.initials: C
authors.lastname: van der Vleuten
authors.affiliation: Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD, 20814, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Durning
mesh_terms: D000328:Adult; D001519:Behavior; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003071:Cognition; D004644:Emotions; D005260:Female; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency / Q000379:methods*; D008297:Male; D010817:Physician-Patient Relations; D011340:Problem Solving; D013850:Thinking; D055815:Young Adult
keywords: Clinical reasoning; Internship and residency; Medical education; Quantitative methods; Situated cognition