Challenges in mitigating context specificity in clinical reasoning: a report and reflection

Objectives Diagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory - which views clinical reasoning as interconnected with surrounding contextual factors - to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group. Methods This study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and "think-aloud" exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA). Results Descriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai's Trace=0.20, F=1.9, df=[4, 29], p=0.15). Conclusions While differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.