Cognitive perspectives on maintaining physicians' medical expertise: II. Acquiring, maintaining, and updating cognitive skills.

Over the course of training, physicians develop significant knowledge and expertise. We review dual-process theory, the dominant theory in explaining medical decision making: physicians use both heuristics from accumulated experience (System 1) and logical deduction (System 2). We then discuss how the accumulation of System 1 clinical experience can have both positive effects (e.g., quick and accurate pattern recognition) and negative ones (e.g., gaps and biases in knowledge from physicians' idiosyncratic clinical experience). These idiosyncrasies, biases, and knowledge gaps indicate a need for individuals to engage in appropriate training and study to keep these cognitive skills current lest they decline over time. Indeed, we review converging evidence that physicians further out from training tend to perform worse on tests of medical knowledge and provide poorer patient care. This may reflect a variety of factors, such as specialization of a physician's practice, but is likely to stem at least in part from cognitive factors. Acquired knowledge or skills gained may not always be readily accessible to physicians for a number of reasons, including an absence of study, cognitive changes with age, and the presence of other similar knowledge or skills that compete in what is brought to mind. Lastly, we discuss the cognitive challenges of keeping up with standards of care that continuously evolve over time.

Piquing Curiosity: Déjà vu-Like States Are Associated with Feelings of Curiosity and Information-Seeking Behaviors.

Curiosity during learning increases information-seeking behaviors and subsequent memory retrieval success, yet the mechanisms that drive curiosity and its accompanying information-seeking behaviors remain elusive. Hints throughout the literature suggest that curiosity may result from a metacognitive signal-possibly of closeness to a not yet accessible piece of information-that in turn leads the experiencer to seek out additional information that will resolve a perceptibly small knowledge gap. We examined whether metacognition sensations thought to signal the likely presence of an as yet unretrieved relevant memory (such as familiarity or déjà vu) might be involved. Across two experiments, when cued recall failed, participants gave higher curiosity ratings during reported déjà vu (Experiment 1) or déjà entendu (Experiment 2), and these states were associated with increased expenditure of limited experimental resources to discover the answer. Participants also spent more time attempting to retrieve information and generated more incorrect information when experiencing these déjà vu-like states than when not. We propose that metacognition signaling of the possible presence of an as yet unretrieved but relevant memory may drive curiosity and prompt information-seeking that includes further search efforts.

Increased pupil dilation during tip-of-the-tongue states.

Tip-of-the-tongue states (TOTs) are feelings of impending word retrieval success during a current failure to retrieve a target word. Though much is known and understood about TOT states from decades of research, research on potential psychophysiological correlates of the TOT state is still in its infancy, and existing studies point toward the involvement of neural processes that are associated with enhanced attention, motivation, and information-seeking. In the present study, we demonstrate that, during instances of target retrieval failure, TOT states are associated with greater pupillary dilation (i.e., autonomic arousal) in 91% of our sample. This is the first study to demonstrate a pupillometric correlate of the TOT experience, and this finding provides an important step toward understanding emotional attributes associated with TOT states. Mean pupil dilation also increased such that instances of target identification failure that were unaccompanied by TOT states < instances in which TOTs occurred < instances of target identification success. It is possible that TOTs reflect an intermediary state between complete target retrieval failure and full target retrieval.

Failures of memory and the fate of forgotten memories.

This review is intended primarily to provide cognitive benchmarks and perhaps a new mindset for behavioral neuroscientists who study memory. Forgetting, defined here broadly as all types of decreases in acquired responding to stimulus-specific eliciting cues, is commonly attributed to one or more of the following families of mechanisms: (1) (4) associative interference by information similar to, but different from the target information, (2) spontaneous decay of memory with increasing retention intervals, (3) displacement from short-term memory by irrelevant information, and (4) inadequate retrieval cues at test. I briefly review each of these families and discuss data suggesting that many apparent instances of spontaneous forgetting and displacement from short-term memory can be viewed as variants of inadequate retrieval cues and associative interference. The potential for recovery of target information from each of these families of forgetting without further relevant training is then reviewed, with a conclusion that most forgetting is due to retrieval failure as opposed to irreversible erasure of memory. The more general point is made that there are logical problems with ever talking about attenuating or erasing a memory as a consequence of conventional forgetting or disrupted consolidation/reconsolidation. Consideration is then given to the frequently overlooked but highly beneficial consequences of most forgetting. Lastly, the major variables that moderate forgetting are summarized, including (a) the similarities of the target information including training context to the explicit retrieval cues and context present at test, (b) the similarities of potentially interfering acquired information to the retrieval cues and context present at test, and (c) the retention interval for the target information relative to that for the potentially interfering information. Appropriate manipulation of these variables can reduce forgetting, and increase forgetting when desired.

Surgical Removal of the Inferior Vena Cava Filter Using Minimal Cavotomy: A Case Report.

The use of retrievable inferior vena cava (IVC) filters has markedly increased in the recent years. However, the failure rate for the retrieval of the IVC filters using the endovascular method is reported to be up to 19%. Open surgical removal of the IVC filters is technically challenging and may require longitudinal cavotomy, clamping, and repair of the IVC. Here, we present a case of successful open surgical removal of the IVC filter using minimal cavotomy. This technique is an effective method after a failed endovascular removal attempt.

Retrieval activates related words more than presentation.

Retrieving information enhances learning more than restudying. One explanation of this effect is based on the role of mediators (e.g., sand-castle can be mediated by beach). Retrieval is hypothesised to activate mediators more than restudying, but existing tests of this hypothesis have had mixed results [Carpenter, S. K. (2011). Semantic information activated during retrieval contributes to later retention: Support for the mediator effectiveness hypothesis of the testing effect. Journal of Experimental Psychology: Learning, Memory, and Cognition, 37(6), 1547-1552. doi: 10.1037/a0024140 ; Lehman, M., & Karpicke, J. D. (2016). Elaborative retrieval: Do semantic mediators improve memory? Journal of Experimental Psychology: Learning, Memory, and Cognition, 42(10), 1573-1591. doi: 10.1037/xlm0000267 ]. The present experiments explored an explanation of the conflicting results, testing whether mediator activation during a retrieval attempt depends on the accessibility of the target information. A target was considered less versus more accessible when fewer versus more cues were given during retrieval practice (Experiments 1 and 2), when the target had been studied once versus three times initially (Experiment 3), or when the target could not be recalled versus could be recalled during retrieval practice (Experiments 1-3). A mini meta-analysis of all three experiments revealed a small effect such that retrieval activated mediators more than presentation, but mediator activation was not reliably related to target accessibility. Thus, retrieval may enhance learning by activating mediators, in part, but these results suggest the role of other processes, too.

Deconstructing the reactivation of imitation in young infants.

Reactivation is an automatic, perceptual process in which exposure to components of a forgotten event alleviates forgetting. Most research on infant memory reactivation has used conditioning paradigms. We used the puppet imitation task to systematically examine which stimuli could retrieve 6-month-olds' forgotten memory of the modeled actions. Infants watched an adult model a sequence of actions on a puppet, imitated the actions, and were exposed to reactivation cues 24 hr before a 7-day (Experiment 1) or 14-day (Experiment 2) retention test. Exposure to any component of the original event reactivated the memory during the 7-day test, but two of the same components failed to alleviate forgetting during the 14-day test. Increasing the number of retrieval cues facilitated 14-day test performance. These findings reveal that the principles of reactivation are the same for conditioning and imitation paradigms: The necessary and sufficient conditions for memory reactivation are directly related to memory accessibility.

The use of cue familiarity during retrieval failure is affected by past versus future orientation.

Cue familiarity that is brought on by cue resemblance to memory representations is useful for judging the likelihood of a past occurrence with an item that fails to actually be retrieved from memory. The present study examined the extent to which this type of resemblance-based cue familiarity is used in future-oriented judgments made during retrieval failure. Cue familiarity was manipulated using a previously-established method of creating differing degrees of feature overlap between the cue and studied items in memory, and the primary interest was in how these varying degrees of cue familiarity would influence future-oriented feeling-of-knowing (FOK) judgments given in instances of cued recall failure. The present results suggest that participants do use increases in resemblance-based cue familiarity to infer an increased likelihood of future recognition of an unretrieved target, but not to the extent that they use it to infer an increased likelihood of past experience with an unretrieved target. During retrieval failure, the increase in future-oriented FOK judgments with increasing cue familiarity was significantly less than the increase in past-oriented recognition judgments with increasing cue familiarity.