AN INTEGRATED STRATEGY TO PROMOTE HIGHER ORDER THINKING AND REDUCE COGNITIVE DIAGNOSTIC ERRORS THROUGH PHYSICIAN ASSISTANT EDUCATION

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2013-04-12

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Tshuma, Lisa

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Purpose: Diagnostic errors are more likely to result in patient harm than other types of medical errors and are frequently preventable. The primary causes of diagnostic error are breakdowns in our health care systems, clinical reasoning or both. Although significant effort has been placed in developing health care system solutions, relatively little has been done to mitigate the common causes of breakdown in clinical reasoning such as failed perception, implicit bias and failed heuristics. Our project employed a set of active and reflective learning activities in the MPAS 5242 course designed to provide physician assistant (PA) students with tools to reduce cognitive diagnostic errors in clinical practice. Methods: An integrated teaching approach centered on five strategies to decrease diagnostic cognitive error was employed. These strategies include Cognitive Dispositions to Respond (CDR) awareness, consideration of alternatives, metacognition, simulation and decreased reliance on memory. Students were introduced to CDRs through lectures and assigned readings including the book How Doctors Think. Students completed pre-class online quizzes to prepare them for interactive lectures and small group activities, including small group skits. Students completed weekly online Implicit Associations Tests to help them identify subconscious biases that may contribute to cognitive diagnostic errors. Finally, students wrote a reflection paper to synthesize their learning experience. Fifteen reflection papers were randomly selected and evaluated by 2 raters using a rubric measuring students' ability identify potential cognitive errors, analyze the reason(s) they were likely to commit the errors, and apply strategies to avoid future similar errors. To achieve inter-rater reliability, the two raters independently rated the 15 samples, and then met to resolve any discrepancies. Results: Overall, the results showed that students achieved a satisfactory outcome, which was shown by their mean scores in the three parts of the rubric: 2.8 out of 3.0 in the ability to identify cognitive errors, 3.5 out of 5.0 in the ability to analyze potential errors, and 3.0 out of 5.0 in their ability to formulate strategies to prevent the errors. Conclusions: The integrated teaching strategy was effective promoting higher order thinking by providing PA students with tools to reduce cognitive diagnostic errors in their clinical practicums and future clinical practice.

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