A STUDY OF NARRATIVE AS THE COGNITIVIE PROCESS UNDERLYING DIAGNOSTIC REASONING -
DESCRIPTION (provided by applicant): Physicians commonly commit diagnostic errors. Research demonstrates that these are the most dangerous types of medical errors. Diagnosis relies on two cognitive processes: one is fast, automatic, and unconscious, while the other is slow, deliberative, and conscious. Cognitive errors may result from poor integration of these processes. Studies in cognitive science and social psychology suggest that narrative cognition integrates these two processes. The role of narrative cognition in medical diagnosis is not well understood. Early medical training, with its emphasis on rote memorization, may impair a natural human tendency to organize complex information with a narrative structure. Understanding the role of narrative cognition at different training levels may be critical to improving medical training and reducing diagnostic errors. We aim to document differences in the use of narrative cognition in diagnostic reasoning between novices, intermediates, and expert clinicians. We will use semi-structured interviews of practitioners at various levels of training and record their diagnostic approaches to three common causes of shortness of breath. A team that is initially blinded as to the subjects' training level will analyze the interview transcripts. They will identify key cognitive components in the interviews, including proposition frameworks ('if then' rules), semantic structure (how these rules are incorporated into hierarchies of meaning), and non-analytical elements (memories and emotions). Next, the interviews will be unblinded and the team will identify systematic cognitive differences between training levels. We will identify diagnostic errors and possible antecedent causes related to blunted or distorted narrative cognition. Finally, specific recommendations for changes in medical training and avoiding diagnostic errors will be provided. PUBLIC HEALTH RELEVANCE: Medical errors are estimated to cause 44,000 to 98,000 unnecessary deaths per year, and diagnostic errors represent a significant public health threat because they are the most common and most deadly types of medical errors. Medical diagnosis, or misdiagnosis, is a complex psychosocial phenomenon that can be viewed form multiple perspectives. Our multi-disciplinary research team (including experienced medical educators, linguists, cognitive scientists, psychologists, and anthropologists) will characterize a critical cognitive mechanism that contributes to diagnostic error and suggest major ways that diagnostic thinking and medical education can be improved.
