Cognitive elements in clinical decision-making: toward a cognitive model for medical education and understanding clinical reasoning.

Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety and metacognitive awareness were assessed for obstetricians (n = 12) who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression and tree-based classification. Obstetricians with high RC scores were more likely to perform a caesarean section (OR 1.59, p < 0.0001), less likely undertake a mid-forceps or low forceps delivery (OR 0.41, p < 0.0001; OR 0.49, p < 0.0001), and more likely to supervise a spontaneous vaginal delivery (OR 1.17, p = 0.08). Obstetricians with high NFC scores were more likely to perform a caesarean section (OR 1.53, p = 0.03), more likely to undertake a vacuum delivery (OR 5.8, p = 0.001), less likely undertake a mid-forceps delivery (OR 0.45, p = 0.02) and less likely to supervise a spontaneous vaginal delivery (OR 0.47, p < 0.0001). Obstetricians high in trait anxiety were more likely to perform a mid forceps delivery (OR 2.49, p = 0.01) or a vacuum delivery (OR 5.08, p = 0.003), and less likely to supervise a spontaneous vaginal delivery (OR 0.38, p < 0.0001). NFC was negatively associated (OR 0.10, p < 0.001) and trait anxiety was positively associated with intrapartum asphyxia (p < 0.05, rho = 0.582). In summary, physician cognitive processes and affect have a significant impact on patient outcomes, particularly in situations where there is a higher level of clinical unpredictability.

In pursuit of expertise. Toward an educational model for expertise development.

Firstly, the many characteristics of expertise are examined: they include aspects of pattern recognition, knowledge, skill, flexibility, metacognitive monitoring, available cognitive space and teaching abilities. Secondly, three educational models from different domains (Nursing, Surgical Education, Education) are analysed, compared and contrasted, in relation to both educational approach and the development of expertise. Thirdly, a new model for the development of expertise is proposed, incorporating aspects of each of the three previously discussed models. Within this new model, four phases of development are proposed, culminating in the achievement of expertise. Furthermore, it is noted that under certain circumstances performance can deteriorate, and that with appropriate support, there can be recursion back through earlier phases of development. Significant implications for both healthcare education and practice are discussed, in relation to concepts of expertise, potential educational approaches and the proposed model for the development of expertise.