Abstract
BackgroundPhysician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity.MethodsWe created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.FindingsWe recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03).ConclusionsWe found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.
Highlights
Understanding why physicians fail to follow clinical practice guidelines has occupied researchers and policy makers for the past four decades. [1,2,3,4] The dual-process model of cognitive reasoning may help to explain the persistent gap between normative standards and practice patterns. [5] This model posits that two systems of cognitive operations shape judgments: system one processes function intuitively, relying on pattern recognition for answers; system two processes function more laboriously, incorporating rule-based deductions
We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory
The objective of the study was to evaluate the construct validity of a serious game for studying physician decision making, by measuring a) the game’s external validity; b) our ability to manipulate one task condition, cognitive load; and c) participants’ responses to those manipulation, in terms of their consistency with predictions based on cognitive theory, predicting increased reliance on heuristics under greater cognitive load
Summary
Understanding why physicians fail to follow clinical practice guidelines has occupied researchers and policy makers for the past four decades. [1,2,3,4] The dual-process model of cognitive reasoning may help to explain the persistent gap between normative standards and practice patterns. [5] This model posits that two systems of cognitive operations shape judgments: system one (heuristic) processes function intuitively, relying on pattern recognition for answers; system two (analytic) processes function more laboriously, incorporating rule-based deductions. Understanding why physicians fail to follow clinical practice guidelines has occupied researchers and policy makers for the past four decades. [1,2,3,4] The dual-process model of cognitive reasoning may help to explain the persistent gap between normative standards and practice patterns. [7] As a result, researchers must draw inferences about cognitive processes by examining decisions made under systematically varying conditions. In principle, retain clinical validity by simulating representative task environments, while allowing the experimental manipulation of task conditions that can reveal cognitive processes [13]. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making.
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