Heuristics and semantic spaces for the analysis of students' work in mathematical problem solving.

In this research, our objective is to characterize the problem-solving procedures of primary and lower secondary students when they solve problems in real class conditions. To do so, we rely first on the concept of heuristics. As this term is very polysemic, we exploit the definition proposed by Rott (2014) to develop a coding manual and thus analyze students' procedures. Then, we interpret the results of these analyses in a qualitative way by mobilizing the concept of semantic space (Poitrenaud, 1998). This detailed analysis of students' procedures is made possible by collecting audiovisual data as close as possible to the students' work using an action camera mounted on the students' heads. We thus succeed in highlighting three different investigation profiles that we have named explorer, butterfly, and prospector. Our first results tend to show a correlation with these profiles and the success in problem-solving, yet this would need more investigation.

How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis.

Historically, recordkeeping has been an essential task for health professionals. Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. A document analysis based on the approach presented in Bacchi's "What's the problem represented to be?" was applied. Forty practical documents in the form of guidelines, strategies, and quality control documents were included. The analysis uncovered three problem representations: lack of coherence between health services in a complex healthcare system, lack of assessable data for management and political prioritization, and inefficiency in the healthcare system. The proposed solution is a digitalized and standardized practice that transforms recordkeeping in the municipalities. However, municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with task-oriented practices supplied by an anonymous health professional. We find that digital documentation functions as an organizational micromanagement approach that assigns the health professional a subject position as an employee acting according to the organization's framework rather than the profession's normative framework.

Search and Evaluation of Coevolving Problem and Solution Spaces in a Complex Healthcare Design Science Research Project.

This research employs design ethnography to study the design process of a design science research (DSR) project conducted over eight years. The DSR project focuses on chronic wounds and how Information Technology (IT) might support the management of those wounds. Since this is a new and complex problem not previously addressed by IT, it requires an exploration and discovery process. As such, we found that traditional DSR methodologies were not well-suited to guiding the design process. Instead we discovered that focusing on search, and in particular, the co-evolution of the problem and solution spaces, provides a much better focus for managing the DSR design process. The presentation of our findings from the ethnographic study includes a new representation for capturing the co-evolving problem/solution spaces, an illustration of the search process and co-evolving problem/solution spaces using the DSR project we studied, the need for changes in the purpose of DSR evaluation activities when using a search-focused design process, and how our proposed process extends and augments current DSR methodologies. Studying the DSR design process generates the knowledge that research project managers need for managing and guiding a DSR project, and contributes to our knowledge of the design process for research-oriented projects. Managerial Relevance Statement: From a managerial perspective, studying the design process provides the knowledge that research project managers need for managing and guiding DSR projects. In particular, research project managers can guide the search process by understanding when and why to explore different search spaces, to expand the solutions investigated, and to focus on promising solutions and to evaluate them. Overall, this research contributes to our knowledge of design and the design process, especially for highly research-oriented problems and solutions.

Problem representation and diagnostic accuracy during an OSCE.

PURPOSE: The National Academy of Medicine has called for "identifying opportunities to improve the diagnostic process". We studied the association between problem representation and diagnostic accuracy during an objective structured clinical exam (OSCE). MATERIALS AND METHODS: We conducted a non-randomized controlled trial during a ten-case OSCE. We measured whether a summary statement prompt increased the likelihood that the student listed the correct diagnosis and whether better summary statements were correlated with diagnostic accuracy. RESULTS: 114 students provided 1135 responses. The non-prompted control group yielded 631 responses, listing the correct diagnosis first 73% of the time and within the top three slots 85% of the time. The intervention group exposed to the prompt yielded 453 responses listing the correct diagnosis first 72% of the time (P = 0.617) and within the top three slots 84% of the time (P = 0.760). Summary statements were scored on a 0, 0.5, or 1 rubric. When grouped according to summary statement score, students listed the correct diagnosis first 74%, 70%, and 72% of the time respectively (P = 0.666). The correct diagnosis was included within the top three slots 88%, 82%, and 83% of the time (P = 0.238). CONCLUSIONS: Prompting students to form a summary statement did not improve diagnostic accuracy. Better summary statements were not correlated with diagnostic accuracy.

Voluntary food fortification policy in Australia: did 'formal' stakeholder consultation influence the outcome?

This research aimed to understand how the policy was represented as a 'problem' in food regulatory decision-making in Australia, and the implications for public health nutrition engagement with policy development processes. Bacchi's 'what's the problem represented to be?' discourse analysis method was applied to a case study of voluntary food fortification policy (VFP) developed by the then Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC) between 2002 and 2012. As a consultative process is a legislated aspect of food regulatory policy development in Australia, written stakeholder submissions contributed most of the key documents ascertained as relevant to the case. Four major categories of stakeholder were identified in the data; citizen, public health, government and industry. Predictably, citizen, government and public health stakeholders primarily represented voluntary food fortification (VF) as a problem of public health, while industry stakeholders represented it as a problem of commercial benefit. This reflected expected differences regarding decision-making control and power over regulatory activity. However, at both the outset and conclusion of the policy process, the ANZFRMC represented the problem of VF as commercial benefit, suggesting that in this case, a period of 'formal' stakeholder consultation did not alter the outcome. This research indicates that in VFP, the policy debate was fought and won at the initial framing of the problem in the earliest stages of the policy process. Consequently, if public health nutritionists leave their participation in the process until formal consultation stages, the opportunity to influence policy may already be lost.

Lessons in clinical reasoning - pitfalls, myths, and pearls: a woman brought to a halt.

OBJECTIVES: Limitations in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with a diagnosis, as well as how discordance of data can help advance the reasoning process, may reduce such errors. CASE PRESENTATION: A 60-year-old woman with Hashimoto thyroiditis, diabetes, and generalized anxiety disorder presented with diffuse arthralgias and myalgias. She had been evaluated by physicians of various specialties and undergone multiple modalities of imaging, as well as a electromyography/nerve conduction study (EMG/NCS), leading to diagnoses of fibromyalgia, osteoarthritis, and lumbosacral plexopathy. Despite treatment for these conditions, she experienced persistent functional decline. The only definitive alleviation of her symptoms identified was in the few days following intra-articular steroid injections for osteoarthritis. On presentation to our institution, she appeared fit with a normal BMI. She was a long-time athlete and had been training consistently until her symptoms began. Prediabetes had been diagnosed the year prior and her A1c progressed despite lifestyle modifications and 10 pounds of intentional weight loss. She reported fatigue, intermittent nausea without emesis, and reduced appetite. Examination revealed intact strength and range of motion in both the shoulders and hips, though testing elicited pain. She had symmetric hyperreflexia as well as a slowed, rigid gait. Autoantibody testing revealed strongly positive serum GAD-65 antibodies which were confirmed in the CSF. A diagnosis of stiff-person syndrome was made. She had an incomplete response to first-line therapy with high-dose benzodiazepines. IVIg was initiated with excellent response and symptom resolution. CONCLUSIONS: Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid misdiagnosis and halt diagnostic inertia. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. The case discussant demonstrates the power of iterative reasoning, case progression without commitment to a single diagnosis, and the dangers of both explicit and implicit bias. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to overcoming diagnostic inertia.

Assisting the Learning of Clinical Reasoning by Veterinary Medical Learners with a Case Example.

Effective clinical reasoning is essential for veterinary medical education, particularly in managing complex cases. This review explores strategies for learning clinical reasoning by veterinary medical learners, using a case example of mastitis to illustrate key concepts. Clinical reasoning encompasses cognitive, metacognitive, social, and situational activities, yet the literature on practical applications in veterinary education remains limited. The review discusses various stages of clinical reasoning, including data collection, problem representation, differential diagnosis, and management planning. It emphasizes the importance of integrating client-centered care and iterative evaluation into the clinical decision-making process. Key learning strategies include facilitation in using the domains of clinical reasoning-concepts, data collection, and analysis, taking action, and reflection on encounters. This review highlights best practices such as forward and backward reasoning, reflective practice, and the use of practical examples to enhance learners' diagnostic accuracy and patient outcomes. The insights provided aim to enhance the training of veterinary learners, ensuring they can navigate day 1 as well as complex cases with improved diagnostic accuracy and patient outcomes.

When is Psychology Research Useful in Artificial Intelligence? A Case for Reducing Computational Complexity in Problem Solving.

A problem is a situation in which an agent seeks to attain a given goal without knowing how to achieve it. Human problem solving is typically studied as a search in a problem space composed of states (information about the environment) and operators (to move between states). A problem such as playing a game of chess has 10 120 $10^{120}$ possible states, and a traveling salesperson problem with as little as 82 cities already has more than 10 120 $10^{120}$ different tours (similar to chess). Biological neurons are slower than the digital switches in computers. An exhaustive search of the problem space exceeds the capacity of current computers for most interesting problems, and it is fairly clear that humans cannot in their lifetime exhaustively search even small fractions of these problem spaces. Yet, humans play chess and solve logistical problems of similar complexity on a daily basis. Even for simple problems humans do not typically engage in exploring even a small fraction of the problem space. This begs the question: How do humans solve problems on a daily basis in a fast and efficient way? Recent work suggests that humans build a problem representation and solve the represented problem-not the problem that is out there. The problem representation that is built and the process used to solve it are constrained by limits of cognitive capacity and a cost-benefit analysis discounting effort and reward. In this article, we argue that better understanding the way humans represent and solve problems using heuristics can help inform how simpler algorithms and representations can be used in artificial intelligence to lower computational complexity, reduce computation time, and facilitate real-time computation in complex problem solving.

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis.

OBJECTIVES: Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. CASE PRESENTATION: This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1-2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. CONCLUSIONS: Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

Hickam's dictum, Occam's razor, and Crabtree's bludgeon: a case of renal failure and a clavicular mass.

OBJECTIVES: Our discussant's thoughtful consideration of the patient's case allows for review of three maxims of medicine: Occam's razor (the simplest diagnosis is the most likely to be correct), Hickam's dictum (multiple disease entities are more likely than one), and Crabtree's bludgeon (the tendency to make data fit to an explanation we hold dear). CASE PRESENTATION: A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team's working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient's renal failure was more likely a result of a chronic, unrelated process. CONCLUSIONS: It is tempting to bludgeon diagnostic possibilities into Occam's razor. Presumption that a patient's signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam's dictum than to Occam's razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.

When the Solution Is on the Doorstep: Better Solving Performance, but Diminished Aha! Experience for Chess Experts on the Mutilated Checkerboard Problem.

Insight problems are difficult because the initially activated knowledge hinders successful solving. The crucial information needed for a solution is often so far removed that gaining access to it through restructuring leads to the subjective experience of "Aha!". Although this assumption is shared by most insight theories, there is little empirical evidence for the connection between the necessity of restructuring an incorrect problem representation and the Aha! experience. Here, we demonstrate a rare case where previous knowledge facilitates the solving of insight problems but reduces the accompanying Aha! experience. Chess players were more successful than non-chess players at solving the mutilated checkerboard insight problem, which requires retrieval of chess-related information about the color of the squares. Their success came at a price, since they reported a diminished Aha! experience compared to controls. Chess players' problem-solving ability was confined to that particular problem, since they struggled to a similar degree to non-chess players to solve another insight problem (the eight-coin problem), which does not require chess-related information for a solution. Here, chess players and non-chess players experienced the same degree of insight.

Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of chest pain and shortness of breath.

Background Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and "can't miss" diagnoses may reduce such errors. Case presentation A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE). Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.

Orienting to see what's important: Learn to ignore the irrelevant.

The current study used a triad judgment task to assess whether blocking by comparison type in a triad judgment task could lead people to pay less attention to surface-level (irrelevant) features and pay more attention to deep (structural) features of information. A sample of 313 participants recruited through Mechanical Turk participated in this study. On each triad, participants were asked to evaluate which of two source scenarios went best with the target scenario. Three types of triads were constructed with materials related to the ability to perceive ethical issues within the practice of psychology. One type of triad contrasted a scenario that was similar to the target in terms of surface-level features and a scenario that was similar in terms of deep features (similar surface-similar deep, SS/SD). A second triad type contrasted a scenario that was similar in terms of deep features with an unrelated scenario (similar deep-unrelated, SD/U). The third contrasted a scenario that was similar in terms of surface features with an unrelated scenario (similar surface-unrelated, SS/U). There were 10 triads of each type. We found that with all the blocking orders except two, participants reliably chose the SS scenario over the SD scenario for the SS/SD triads. However, participants who started out with the SD/U triads did not. The results provide evidence that people often have the ability to perceive the deep, but they are distracted by the surface-level features. The results also show that people can be oriented away from being distracted by the surface-level features so that they can see the deep.

Diagnosing and Remediating Clinical Reasoning Difficulties: A Faculty Development Workshop.

Introduction: Clinical reasoning is a complex cognitive process that involves multiple steps. Diagnosing and remediating clinical reasoning difficulties requires faculty to have an understanding of the cognitive theory behind clinical reasoning, familiarity with terminology, and a framework to identify different domains of struggle in their learners. Published resources on faculty development to diagnose and remediate clinical reasoning difficulties are limited. We created and implemented a workshop to assist faculty in developing these skills based on the five-domain framework described by Audétat, Laurin, and Sanche. This workshop provides all the materials needed to replicate this training with faculty at other institutions. Methods: The workshop consists of a didactic component and case-based active learning in small groups. Each case focuses on different domains of clinical reasoning difficulties and targets different learner levels (preclinical medical students through residents). The workshop was given in multiple venues in 2016 and 2017. Results: Participants reported the session was valuable (4.71/5.0), the facilitators were effective (4.5/5.0), and the objectives were met (4.28/5.0). They highlighted the strengths of the interactive format, the framework to diagnose and remediate clinical reasoning difficulties, and the excellent take-home resources. They suggested more time for the workshop, revision of cases to better highlight difficulties, and refinement of instructions to approach the cases. These suggestions were incorporated into the current iteration of the workshop. Discussion: We successfully implemented a workshop for diagnosing and remediating clinical reasoning difficulties in multiple venues. The sessions were diverse in terms of faculty participants and learner groups addressed.

Using standardized patients versus video cases for representing clinical problems in problem-based learning.

PURPOSE: The quality of problem representation is critical for developing students' problem-solving abilities in problem-based learning (PBL). This study investigates preclinical students' experience with standardized patients (SPs) as a problem representation method compared to using video cases in PBL. METHODS: A cohort of 99 second-year preclinical students from Inje University College of Medicine (IUCM) responded to a Likert scale questionnaire on their learning experiences after they had experienced both video cases and SPs in PBL. The questionnaire consisted of 14 items with eight subcategories: problem identification, hypothesis generation, motivation, collaborative learning, reflective thinking, authenticity, patient-doctor communication, and attitude toward patients. RESULTS: The results reveal that using SPs led to the preclinical students having significantly positive experiences in boosting patient-doctor communication skills; the perceived authenticity of their clinical situations; development of proper attitudes toward patients; and motivation, reflective thinking, and collaborative learning when compared to using video cases. The SPs also provided more challenges than the video cases during problem identification and hypotheses generation. CONCLUSION: SPs are more effective than video cases in delivering higher levels of authenticity in clinical problems for PBL. The interaction with SPs engages preclinical students in deeper thinking and discussion; growth of communication skills; development of proper attitudes toward patients; and motivation. Considering the higher cost of SPs compared with video cases, SPs could be used most advantageously during the preclinical period in the IUCM curriculum.

Teaching Clinical Reasoning to Medical Students: A Case-Based Illness Script Worksheet Approach.

INTRODUCTION: Clinical reasoning is a fundamental part of a physician's daily workflow. Yet it remains a challenging skill to develop formally, especially in preclerkship-level early learners. Traditionally, medical students learn clinical reasoning informally through experiential opportunities during their clerkship years. This occurs in contrast to the more structured, explicit learning of the basic sciences and physical diagnosis during the preclerkship years. To address this need, we present a flipped classroom case-based approach for developing clinical reasoning skills based on problem representation and the use of a structured illness script worksheet as a model. METHODS: Students were given a short introduction via screencast to introduce clinical reasoning and related terminology such as problem representation and semantic qualifiers. They also received a case vignette and an illness script worksheet to prepare them for in-class discussion. Students used this worksheet to practice clinical reasoning in a small-group session that was held in our last organ system-based second-year course, prior to the start of the clerkships. RESULTS: In comparison to the traditional facilitator-led small-group sessions, where students would sequentially answer a set of defined content-based questions to explore a clinical case, 80% of students preferred the new framework that incorporates problem representation and the illness script worksheets. Faculty facilitators found the structure of the illness script worksheet helpful in leading a clinical reasoning small-group session. DISCUSSION: Based on the results of this pilot, we plan to systematically implement this clinical reasoning framework in our preclerkship curriculum.

Using standardized patients versus video cases for representing clinical problems in problem-based learning / 한국의학교육

PURPOSE: The quality of problem representation is critical for developing students' problem-solving abilities in problem-based learning (PBL). This study investigates preclinical students' experience with standardized patients (SPs) as a problem representation method compared to using video cases in PBL. METHODS: A cohort of 99 second-year preclinical students from Inje University College of Medicine (IUCM) responded to a Likert scale questionnaire on their learning experiences after they had experienced both video cases and SPs in PBL. The questionnaire consisted of 14 items with eight subcategories: problem identification, hypothesis generation, motivation, collaborative learning, reflective thinking, authenticity, patient-doctor communication, and attitude toward patients. RESULTS: The results reveal that using SPs led to the preclinical students having significantly positive experiences in boosting patient-doctor communication skills; the perceived authenticity of their clinical situations; development of proper attitudes toward patients; and motivation, reflective thinking, and collaborative learning when compared to using video cases. The SPs also provided more challenges than the video cases during problem identification and hypotheses generation. CONCLUSION: SPs are more effective than video cases in delivering higher levels of authenticity in clinical problems for PBL. The interaction with SPs engages preclinical students in deeper thinking and discussion; growth of communication skills; development of proper attitudes toward patients; and motivation. Considering the higher cost of SPs compared with video cases, SPs could be used most advantageously during the preclinical period in the IUCM curriculum.