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Table 1 Cognitive dispositions to respond (CDR) themes and representative excepts

From: A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions

 

Representative Excerpt 1

Representative Excerpt 2

Cognitive Biases -“representations that are systematically distorted compared to some aspect of objective reality.” [39]

Anchoring Bias - the tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in the light of later information [8].

Based on the fact that there’s some sort of link to the football game, I went ahead and just went with inhalation anthrax ...umm... ‘cuz maybe the…it was disseminated ...umm... somewhere where they were sitting and…they…they all inhaled the…the …uhh… pathogen and got sick. - Participant #11, Item ID.1

I was a little bit rushed through this one, but … umm… was interested in the last couple sentences where you were looking at the patchy right lower lobe infiltrate…umm… And I…was thinking about inhalational or aspiration pneumonia… - Participant #1, Item ID.5

Availability & Non-Availability Bias - the disposition to judge things as being more (or less) likely, or frequently occurring, based on how readily (or not) they come to mind. Thus, recent exposure to / experience with a disease (OR medication, approach to management, etc.) may inflate the likelihood of its being diagnosed (OR used) [8].

And I know a lot of the things I’ve seen…like…kind of if you’re doing antibiotics, you always cover for pseudomonas. I remember people always saying cover for pseudomonas if we’re gonna cover for anything, so that kind of pops in my head. – Participant #9, Item ID.5

Actually what I would probably done is look up what the current therapy is, ‘cuz I haven’t treated Paget’s disease in probably 10 years, so… Umm…. uhh… I gave an answer to this question…alendronate, because it…it’s what I would have done in the past, but I actually feel inadequate about that answer. – Participant #6, Item DB.2

Commission Bias - results from the obligation toward beneficence, in that harm to the patient can only be prevented by active intervention. It is the tendency toward action rather than inaction [8]. MORE IS BETTER

I didn’t…umm… choose C or D, and if you’re going to give them a supplement of calcium, you might as well just slam them with the Vitamin D supplement as well…umm…So that’s why I chose B. I figured that would be better than just calcium alone. – Participant #1, Item DB.5

Basically it got me down to quest…to…this is test taking…this…that got me to C or to D. And then the issue was…umm…the only difference between C and D is whether or not you start a bisphosphonate …umm… at this point, or not. And…I actually wasn’t sure, but I had…I, actually, had leaned…umm… toward doing it, so I answered D. The…everything about the question says this is…this is a patient who’s likely to be on …umm… long-term prednisone, and therefore, at…umm… at risk for developing osteoporosis. And that’s it. – Participant #5, Item DB.5

Gambler’s Fallacy - The pretest probability that a patient will have a particular diagnosis might be influenced by preceding but independent events. Attributed to gamblers, this fallacy is the belief that if a coin is tossed ten times and is heads each time, the 11th toss has a greater chance of being tails (even though a fair coin has no memory) [8].

Umm… calcitonin, I said for the bone turnover question, so I figured it wouldn’t apply to this one. – Participant #2, Item DB.3

I didn’t think it was Dementia with Lewy Bodies, because I was looking for motor signs and symptoms there, and I had already used that answer. – Participant #11, Item NCD.4

Omission Bias - the tendency toward inaction and rooted in the principle of non-maleficence [8].

LESS IS MORE

D says to start bisphosphonate. I don’t think you necessarily start somebody bisphosphonates …uhh… without sort of confirming that diagnosis. – Participant #10, Item DB.5

maybe, alendronate…maybe that drug would work better if it was given …uhh… as a different …umm… route and class, so I thought the substituting for intravenous zoledronate [throat clear] … for the alendronate, or choice ‘D,’ was gonna be the correct one, because of the way that it modified the therapy …umm… without …uhh… adding in something new. – Participant #2, Item DB.1

Playing the Odds (Frequency Gambling) - the tendency in equivocal or ambiguous presentations to opt for a benign explanation on the basis that it is significantly more likely than a serious one [16].

Uhh… again, looking at the lab values, I was trying to remember what normal was, and I was going back and forth trying to figure out if testosterone was low or normal, and… decided that it was normal at 50. ...umm... and the free T4, again, guessing if that was normal or elevated, and I couldn’t recall, so I st…interpreted as normal. –Participant #8, Item DB.4

and he only lost points on recall and ...umm... the orientation section for the date though. So…and I don’t even know the date, so I’m not concerned about that. – Participant #9, Item NCD.1

Premature Closure - Accepting a diagnosis before it has been fully verified, essentially limiting answers or selecting final answer early. Related to anchoring [8].

So…so (stutters), from the start, I was thinking this was community-acquired pneumonia …umm… but, the only weird thing was the friend who died yesterday, so…(stutters)it didn’t really affect…I …I couldn’t really make too much sense of that, but I went ahead and selected B for the answer for that. –Participant #3, Item ID.1

Physical exam ...uhh... she has cog wheeling. So right off the bat, cog wheeling sort of triggers me to think ...umm... Parkinsonian, or ...umm... Parkinsonian dementia or related, which would be a Lewy Body dementia ...umm... So really with that, I almost skipped down to the bottom, and I say “Well this is unlikely to be Alzheimer’s or Creutzfeldt Jakob.” The Parkinsonian fits with, sort of, the characteristic exam findings ...umm... So I would say right off the bat that this is Dementia with Lewy Bodies. And I look at the other choices just to make sure I’m not missing anything, but again, they don’t really fit in terms of stepwise for vascular, or speech and ...uhh... behavioral things for frontotemporal. –Participant #14, Item NCD.3

Representativeness Restraint - drives the diagnostician toward looking for prototypical manifestations of disease. Yet restraining decision-making along these pattern-recognition lines may lead to atypical variants being missed [16].

determined that this couldn’t be vascular dementia, ‘cuz it wasn’t “step-wise” –Participant #3, Item NCD.4

Staph aureus would be a consolidated chest x-ray, so that’s out. –Participant #14, Item ID.2

Flaws in Conceptual Understanding - demonstrable evidence of an incorrect or inadequate basis in knowledge of the concepts presented in the clinical vignette or addressed by the participant

Perceptual Flaws - where key information presented in the MCQ item was missed by the participant, misunderstood or misinterpreted, or instances where participants erroneously added information that they then used in their reasoning.

The blood smear showed gram negative coccobacilli…and I took…I didn’t actually see the first time, there was this blood smear. I just know that somewhere (laughing), this was found. (incomprehensible) It doesn’t really sway me either way, but what…either way he’s got some gram negative cocco….coccobacilli. – Participant #9, Item ID.4

Uhh… oh! wait a minute. She’s on pentamidine. I didn’t even notice that. Hmm… (long pause…lip smack…vocalizations)… well I don’t know the effectiveness of pentamidine in preventing pneumocystis, which is why it is there; however, as seeing that she was on the pentamidine, I should probably choose something else, although I’m not allowed to change my answer now. I would probably change it to something else. –Participant #6, Item ID.2

Inappropriate Rule Application - instances where participants used a general rule that was either conceptually invalid, or when a general rule was clearly used inappropriately.

So this is a older gentleman …uhh… with 2 day history of fever, cough, and yellow sputum. So its a productive cough. He’s also febrile, so that tells me that he likely has a blood stream infection somewhere. – Participant #8, Item ID.5 (Note: This is a rule in which Fever is inappropriately equated to a Blood Stream Infection/bacteremia)

So I scan through the list real quick and… right off the bat the last two - staphylococcus and streptococcus - I think are…are …uhh.. both very unlikely because you… you would see more of the …umm… the CBC would be different because you would see neutrophils…you’d see more of …uhh… bacterial reaction …umm… --Participant #2, Item ID.2 (Note: This is a heuristic that Bacterial Pneumonia causes leukocytosis incorrectly applied in Immunosuppressed patient)

Incomplete Conceptual Knowledge Structure - Instances when the participant demonstrated clear evidence of poor conceptual understanding or a knowledge gap (i.e., self-reflective statement of knowledge deficit, expressing factually incorrect information, etc.).

Umm… so the thought then either…either should be coverage for Nocardia or for Pseudomonas. Umm… and again, this is just a knowledge gap for me. I don’t know, in people who have bronchiectasis, if…if they are particularly predisposed to one or the other of these. – Participant #5, Item ID.5

And because …umm… it has calcifications in the spleen and mediastinum, I’m thinking this thing moves around in the blood okay without being detected very easily - so I don’t think the serology is necessarily going to happen, nor the fungal blood cultures. And so I…I assume that the urinary antigen detection …uhh… would be the most …would be the best answer …umm… because I feel like a metabolic detection would be better than trying to grow a fungus from …hoping that you catch little bits of it from either the blood or serum. – Participant #2, Item ID.3

Semantic Discompetence (Subtheme) - using terms incorrectly or in a manner that demonstrates very poor understanding of the concept represented by the term.

Fungal blood culture, I opted against, because he didn’t appear to show any evidence of bacteremia. – Participant #8, Item ID.3

Like, I know if its mild cognitive impairment, it’s just memory loss, it’s not something that’s actually pathologic. – Participant #9, Item NCD.1

“Other” Vulnerabilities - possible vulnerabilities related to the CDR framework but that did not fall clearly into the other categories more clearly framed by the existing literature on CDRs.

Emotional Reactions - The influence of affective sources. Coded with the presence of verbalized affective / emotional response. Difficult to code in more detail as suggested by literature given the nature of the TA data. Only able to code fairly explicit expressions of emotion.

What confirms the diagnosis? is the question. So I know I’m not looking at diagnosis question. It seems like a second order thing, so its going to be a bit more annoying. – Participant #9, Item ID.3

Uhh…wow that is pretty close to my age…is …uhh… She’s losing memory …uhh… and worsening over the past year, which is concerning. – Participant #10, Item NCD.2

Marked Uncertainty - the act of selecting an answer without evidence of reasoning to support that answer. This code is often associate with the use of phrases like “just a guess” or “50/50” indicated “Guessing” OR expressions of uncertainty.

and between Salmonella and Yersinia…umm… I was not sure which one looked like safety pins…umm… I think I vaguely remember its salmonella…umm… but that was more of a 50/50 shot, but I chose salmonella for the gram negative coccobaccilli that looked like safety pins, −-Participant #1, Item ID.4

so then, I’ve got two choices…umm… that it came down to, and again, I don’t…I don’t know the intravenous bisphosphonates well enough, so I essentially just basically took a guess then and said C. – Participant #5, Item DB.3