DEVELOPING ASSESSMENT TOOLS TO BETTER UNDERSTAND THE MECHANISMS OF CLINICAL REASONING IN MILITARY MEDICAL SIMULATION

Background: Reducing medical errors is a societal goal. Errors in clinical reasoning have been identified as an important etiological factor in medical errors. Theories about expertise have been insufficient in explaining the occurrence of errors. These theories suggest that someone is an expert or novice based on a stable personal trait, but this does not help us to understand why clinical problem-solving performance can be variable both in experts and novices. Modern theories, instead, look at expertise as problem-specific performance, and experts are more likely to display expert clinical performance because they are more likely to have problem-specific experience. Modern theories also recognize the interaction between the problem solver and other contextual factors (CFs) and that these may influence performance. But simply stating that there is an interaction and that the world is complex does not help us improve clinical expert performance or decrease the incidence of medical errors. A better understanding of the interplay between extraneous factors and expert performance is needed.Objective/Hypothesis: This project aims to better understand the nature of CFs and how they interplay with clinical expert performance. We hope to build better theories to explain the intra-person and inter-person variability of clinical performance. These theories and associated measures will be tested and used to design an intervention.Specific Aims:Aim 1: Examine how theoretically derived variables are related to clinical reasoning performance in vitro (using videotapes).Aim 2: Examine how theoretically derived variables are related to clinical reasoning performance in vivo (using live scenario-based simulation(s)).Aim 3: Evaluate whether a novel educational intervention based on the results of Aims 1 and 2 improves clinical reasoning performance.Study Design: We propose a three-phase, mixed-methods study design. Phase 1 involves developing videos to be used for Aim 1 (control videos without CFs and videos with CFs) and our acute surgical trauma team scenario. We have previously used videotapes successfully to portray CFs in faculty and residents. Phase 2 of the study involves examining the relationships among CFs, cognitive load, and clinical reasoning performance. Phases 1 and 2 will be completed during the pilot period. Phase 3 entails developing an intervention as well as planning unannounced standardized patient (SP) encounters at Military Treatment Facilities (MTFs) in our area. The timeline for the proposed study is 30 months (2016-2019). We propose a 9-month pilot (for gathering data for Aims 1 and 2) followed by a 21-month intervention (Aim 3) period.Impact: This project will provide a much-needed substantiation to modern theoretical notions about clinical problem solving, not only as to their suitability but also to produce a better understanding of how the various factors around clinical problem-solving interact with each other. The scientific relevance of this project is expected to be very high because our understanding of these factors -- and the way they interact with the clinical problem solver and influence the quality of the clinical problem solution -- is still very limited. Moreover, greater understanding is needed before further research in this area can be conducted. The societal impact of this project is potentially large because its results will lead to the development of more targeted educational interventions to improve problem-specific expert performance and will equip the clinician with strategies to moderate the influence of extraneous factors on their clinical performance.