Clinical decision-making and adaptive expertise in residency: a think-aloud study

Area of Science:

• Cognitive Science in Medicine
• Medical Education Research
• Physician Decision-Making Processes

Background:

• Clinical decision-making (CDM) is crucial for physicians, often explained by dual-process theory.
• Less is known about how situated cognition and adaptive expertise shape novice physicians' CDM.
• Novice physicians require adaptive strategies to compensate for limited experience.

Purpose of the Study:

• To analyze how residents utilize and develop adaptive expert cognition in a natural clinical setting.
• To explore residents' clinical decision-making strategies through verbalized thought processes, guided by the adaptive expert framework.

Main Methods:

• Concurrent and retrospective think-aloud interviews conducted in an emergency department.
• Protocol analysis to map cognitive strategies from residents' verbalizations.
• Narrative analysis comparing identified strategies with adaptive expertise literature.

Main Results:

• Epistemic distance and self-regulating processes were observed during clinical decision-making.
• Premature hypothesis testing led to more laborious decision-making for residents.
• Tolerating uncertainty and clarifying professional roles were vital for developing adaptive decision-making competency.

Conclusions:

• Adaptive expertise in novice physicians is linked to contextual support and professional role clarity.
• Promoting professional development by allowing for uncertainty enhances adaptive decision-making skills.
• This study highlights the importance of situated cognition in shaping clinical decision-making for early-career physicians.