|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 3 | Page : 153-159
How does Patient Management Knowledge Integrate into an Illness Script?
Alireza Monajemi1, Ehsan Rajabi Rostami2, Shokoufeh Savaj3, Remy MJP Rikers4
1 Philosophy of Science Department, Institute for Humanities and Cultural Studies, Tehran, Iran
2 Internal Medicine Resident, Medical School, Tehran University of Medical Sciences, Tehran, Iran
3 Medical School, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Psychology, Erasmus University, Rotterdam, Netherlands
|Date of Web Publication||29-Mar-2013|
Institute for Humanities and Cultural Studies, 64th Street, Kurdestan Expressway, Tehran, Iran, PO Box:14155-6419, Postal Code:14377-74681
Source of Support: None, Conflict of Interest: None
Context: Studies in medical expertise have shown that the medical knowledge of physicians is organized in a way that is easily retrievable when they encounter patients. These knowledge structures, called illness scripts, contain various pieces of information, including signs, symptoms, and enabling conditions, concerning a given disease. Illness script research has principally focused on understanding how physicians make diagnoses, while patient management has received much less attention. Although the work on diagnostics has taught us many things about the nature of medical expertise, focusing solely on this aspect provides only a narrow perspective on the subject, resulting in an incomplete depiction of medical experts. The goal of the present study was to experimentally determine how management knowledge plays a role in the development of illness scripts and developing expertise. Materials and Methods: Medical students, interns, and residents were instructed to think aloud while reading a case with either a diagnostic or management focus. The recall protocols were examined in terms of illness script components, as well as diagnostic and management accuracy. Findings: Both residents and interns were sensitive to the focus and generated significantly more management-items when thinking about management than when they were asked to diagnose a clinical case. They also provided more management items than medical students in management-focus. The performance of interns was superficially similar to that of residents in terms of management proportion, but with respect to both diagnostic and management accuracy they resembled medical students. Medical students, in contrast, were very persistent and insensitive to the focus. Conclusions: Medical expertise could be characterized by the emergence of illness scripts that are rich in terms of management knowledge. Illness scripts can generally be applied to any medical encounter that includes diagnosis and management, and expertise research should be extended to cover both domains.
Keywords: Clinical competence, education, internship and residency/Diagnosis, mental recall, medical undergraduate/methods, patient care management/Psychology
|How to cite this article:|
Monajemi A, Rostami ER, Savaj S, Rikers RM. How does Patient Management Knowledge Integrate into an Illness Script?. Educ Health 2012;25:153-9
| Introduction|| |
Immediately upon encountering a comatose middle-aged man with a history of diabetes mellitus who is on sulfonylurea therapy, an experienced physician would know to do bedside glucometry. Upon finding a blood sugar of 40 mg/dl, the experienced physician would order a hypertonic glucose infusion, leading to a prompt return of consciousness in the patient. Thinking about such appropriate behavior of doctors leads us to consider the cognitive events that underlie a physician's decisions. In past decades, research into medical expertise has been concerned with understanding these cognitive mechanisms and, more particularly, with answering questions about how medical knowledge is developed in such a way that turns novice students into skilled physicians. ,, This body of research has, however, principally focused on understanding how physicians make diagnoses, ,,,, while their patient management decisions have received much less attention. ,,, The above scenario reminds us that doctors do much more than providing a diagnosis; a large part of their activity consists of making management plans for patients. ,, Although the work on acquiring skills in diagnostics has taught us many things about the nature of medical expertise, focusing solely on this aspect of the physician's thinking provides only a narrow perspective on the subject, yielding what might be an incomplete depiction of medical expertise. , Improving understanding in this area is important in bringing more depth to the understanding of a medical expert. 
Previous research has shown that doctors possess knowledge structures that enable them to quickly recognize patterns of diseases based on the signs and symptoms (e.g., coma) and background information (e.g., previous history of diabetes) on patients. , These knowledge structures, which are particularly tuned toward use in practical clinical situations, have been called illness scripts. Physicians develop illness scripts during their course of medical education, as they move from novices to experts.  Signs and symptoms and background information of patients are respectively called "consequences" and "enabling conditions" in illness script theory. ,,, The illness scripts of students in the classroom phase of education, however, are not yet tuned toward practical clinical situations and mainly represent their growing biomedical knowledge. As students begin to practice with actual patients this knowledge gradually becomes less prominent while the role of enabling conditions becomes more pronounced. Enabling condition knowledge becomes generally accessible when it fully integrates into their illness scripts, which follows extensive exposure to real patients. ,
To study the role of patient management within the framework of the illness script theory, therefore, it is reasonable to first demonstrate that management plays a role in the development towards expertise. This first step was reported by Monajemi et al.  In their study, when advanced medical students were asked to provide management plans after reading a clinical case, their suggestions were superficial. This finding becomes more interesting in light of their quite elaborate recall when asked to provide diagnoses, suggesting a probable role for management knowledge in the development of medical expertise. In another study by Monajemi and Rikers,  learners of different levels of training were asked to read cases and provide management plans. This study found that management accuracy is an indicator of expertise. The transitional state of the management knowledge of advanced students (interns) could be corroborated by the fact that their plans resembled those of the experts in terms of format, but they were less accurate and nearly the same as those of early students. This study also revealed evidence of poor linkage between the management and diagnostic knowledge among interns, as their plans contained management-related items that occurred repeatedly across cases with no direct association with their own proposed diagnosis, that is their management approaches were general and not disease specific. Monajemi and Rikers  subsequently proposed incorporating these findings into illness script theory. They suggested that management knowledge should be recognized as part of the illness script, and management gradually becomes integrated into physicians' thinking as a result of repeated exposure to real patients during educational experiences. As this education experience requires students to initially provide diagnoses more often than management, students' scripts are initially more diagnostic-oriented. When these students later enter the internship phase of training, they become more responsible for the management task, but their limited experience does not yet allow their nascent management knowledge to fully integrate with their better established diagnostic knowledge.
The goal of the present study was to test whether management knowledge plays a role in the development of illness scripts. To elucidate the way that management knowledge integrates into the illness script, a comparison was made when learners of different levels of expertise attempted to diagnose and manage hypothetical cases. Furthermore, fourth-year medical students, sixth-year students (i.e., interns) and residents were instructed to think aloud while reading cases for their diagnosis or management thinking. These learners were then also asked to recall whatever they could remember from the cases. The recall protocols were examined in terms of illness script components, as well as diagnostic and management accuracy.
Based on the illness script theory, it was expected that in management-focused tasks the proportion of management-related items relayed by study participants would increase with their level of expertise. As the integration of management knowledge into illness script begins at the level of interns, this experimental manipulation, diagnostic vs. management focus, was expected to affect the performance of interns and residents, whereas the medical students' performance would remain largely unaffected across foci. It was also predicted that residents would not only generate more management items relating to the presented case than medical students and interns, but that residents would also provide more accurate diagnostic and management plans. Interns have acquired more knowledge of management than medical students; hence their recall protocols should contain more management-related items, even though these items were expected be less accurate than those of residents.
| Materials and Methods|| |
Thirty-two medical students (16 fourth-year and 16 sixth-year students) from Tehran Medical School in Tehran, Iran, and 16 internal medicine residents from three hospitals in Tehran participated in this study. It takes about 7 years (4 preclinical years and 3 clinical years) to finish medical school at the Tehran School of Medicine. This study's fourth-year (preclinical) medical students had no or very limited hospital experience and their clinical knowledge was based solely on textbooks and lectures. Sixth-year students were in their hospital training phase as interns under the supervision of senior residents and attending physicians. This study's internal medicine residents were engaged in specialty programs in teaching hospitals. We asked participants to voluntarily participate in the study. They were informed that the responses that they provided would be reported anonymously and only at the level of group expertise.
Materials and procedures
We used two cases in the field of internal medicine. One case was identical to the case used by Patel and Groen  and the other one was constructed by two expert physicians at our school. The cases addressed acute bacterial endocarditis  and hypoglycemic coma. Both cases were about one page in length. The order of the cases for all participants was similar, with the same two cases used for participants of all training levels.
Participants were randomly assigned using a random number generator to the management condition or the diagnostic condition. In order to familiarize the participants with the procedure, they were first given the opportunity to read an unrelated case of about the same length and were instructed to think aloud about their approach to the patient.  In the diagnostic condition, participants were told to think aloud for 4 minutes as they were diagnosing the case. Subsequently, they were instructed to write down whatever they remembered from the cases as well as the diagnoses for both cases. In the management condition, participants were also told to think aloud while trying to devise a management plan for the patient. After they verbally addressed the management aspects of a case, they were also asked to write down what they could remember about the cases and their diagnoses. The only reason for imposing a time limit for the thinking-aloud session was to push participants to do the task in a feasible and manageable amount of time. Each participant was tested individually.
The accuracy of provided diagnoses was independently scored by two internists along a scale that ranged from 0 (completely inaccurate) to 100 (completely accurate). For example, if in the case of acute bacterial endocarditis, the diagnosis contained the key concept "endocarditis" 55 points were given. The presence of "sepsis/septicemia", IV drug abuse", or "infection" each contributed 15 points. The kappa score for the two internists' agreement on the diagnostic accuracy was 0.9, indicating a good agreement. The accuracy of management items were also independently assessed by two internists on a similar100-point scale. The kappa score for the two internists' agreement on the management accuracy was 0.85, also indicating good agreement.
The analysis of recall protocols consisted of segmenting the protocols into propositions using a technique based on the work of Patel and Groen.  The essential element in propositional analysis is the segmentation of a protocol into individual propositions corresponding to discrete idea units in the text. As an example, a recall protocol contained the following information: a 70-year-old female with a history of hypertension and hyperlipidemia is admitted to the hospital for shortness of breath. The physical examination reveals elevated jugular venous pressure (JVP) and peripheral edema. The patient is in pulmonary edema and in urgent need of medical intervention, such as digitalization and diuresis. Concerning illness script categories, "Shortness of breath", "elevated JVP", and "edema" are items belonging to consequences, whereas "hyperlipidemia" or "hypertension" relate to the enabling conditions component. Among other components of the illness script of this case, "pulmonary edema" relates to a fault component, that is, the pathophysiological malfunctions that constitute the biomedical core of the disease, whereas "diuretics" and "digitalization" are items related to the management component. To score the protocols, four measures were used based on previous clinical case studies. , The elaborateness of the student's recall was measured by counting the total number of concepts. An expert physician, who had experience with the illness-script categories, was consulted in order to establish a sound basis for classification of propositions under illness script components. The propositions in each component were counted and these figures divided by the total number of propositions extracted and reported. The least significant difference test was used to make post-hoc comparisons between the different expertise groups. Significance level was set at P< 0.05 for all tests. The number and proportion of statements in each of the illness script categories were analyzed using a 3 (level of expertise) by 2 (focus) analysis of variance (ANOVA).
| Results|| |
[Table 1]a and b depict the mean diagnostic accuracy as a function of expertise level in both foci. Analysis showed a main effect of expertise, F (2,37) = 11.30, MSE= 4.16, P> 0.05, η2 =0.37, a non-significant effect of focus, F (1,37) =0.07, MSE= 8.33, P >0.05, η2 = 0, and a non-significant interaction, F (2,37) = 0.97, MSE= 0.36, P >0.05, η2 =0.05. Pairwise comparison indicated that residents provided significantly more accurate diagnoses than medical students and interns. There was no significant difference in accuracy between the two groups of students as well as between both foci in each level.
[Table 2] a-c show the mean number of propositions recalled as a function of expertise level and focus. Analysis showed a main effect of expertise level, F (2,41) = 15.76, MSE = 1291.09, P < 0.05, η2 = 0.43, a significant effect of focus, F (1,41) = 14.29, MSE = 1170.69, P < 0.05, η2 = 0.25, and a significant interaction F (2,41) = 3.39, MSE = 278.40, P < 0.05, η2 = 0.14. Pairwise comparison within each focus showed that in the diagnostic-focus, residents differed marginally from medical students (P=0.07), but there was no significant difference between interns and medical students or residents and interns. In the management focus, both interns and residents produced significantly more propositions than medical students, but there was no significant difference between residents and interns. Furthermore, the volume of recall in both residents and interns was significantly higher in the management focus than in the diagnostic focus, while there was no significant difference in medical students.
The proportion of statements in different illness script categories
Analysis showed a significant main effect expertise level, F (2, 41) = 9.24, MSE = 0.09, P < 0.05, η2 =0.31, a significant main effect of focus, F (1, 41) = 11.25, MSE= 0.11, P < 0.05, η2 = 0.21, and a significant interaction, F (2, 41) = 4.16, MSE = 0.04, P < 0.05, η2 = 0.17. [Table 3] a-c show enabling condition proportion as a function of expertise level and focus. Pairwise comparisons within each focus indicated that while there was no significant difference between levels of expertise in the diagnostic focus, residents and interns produced significantly fewer enabling conditions items than medical students in the management-focus, but no such difference was observed between interns and residents. With respect to differences between diagnostic and management-foci, the results showed no significant difference in medical students, while there was a borderline (P = 0.08) effect in interns. There was a significant effect between two foci in residents in terms of the proportion of enabling conditions items.
[Table 4] a-c show the proportion of consequences identified as a function of expertise level and focus. Analysis revealed significant effect of expertise level, F (2, 41) = 3.82, MSE= 0.03, P < 0.05, η2 = 0.15, but no significance of focus, F (1,41) = 0.76, MSE=0.007, P > 0.05, η2 = 0.01, as well as no significant effect of interaction, F (2,41) = 0.95, MSE =0.009, P > 0.05, η2 = 0.04. Pairwise comparisons within each focus indicated that while there was no significant difference between levels of expertise in the management-focus, there was a mere borderline effect (P = 0.08) in the diagnostic-focus. The results showed no significant difference in all levels between two foci.
[Table 5] a-c, show the proportion of management-items as a function of expertise level and focus. Analysis revealed significant effect of expertise level, F (2, 41) = 14.91, MSE = 0.11, P< 0.05, η2 = 0.42, significant effect of focus, F (1,41) = 54.90, MSE = 0.42, P< 0.05, η2 = 0.57, as well as significant effect of interaction, F (2,41) = 13.92, MSE = 0.10, P<0.05, η2 = 0.40. Pairwise comparisons within each focus indicated that while there was no significant difference between levels of expertise in the diagnostic-focus, residents and interns produced significantly more management-items than medical students in the management-focus, but such difference was not observed between interns and residents. With respect to differences between diagnostic and management- foci, the results showed no significant difference in medical students, while there was a significant effect both in interns and residents between two foci.
The management accuracy of the residents was higher (M = 62.14; SD=24.47) than that of the interns (M = 24.47; SD=16.02). Analysis revealed a significant effect of training level, F (1, 13) = 5.70, MSE= 2383.61, P< 0.05, η2 = 0.53.
| Discussion|| |
The aim of this study was to investigate the role of management knowledge in the development of illness scripts. In order to demonstrate the gradual integration of management knowledge into the illness script structure, participants at different levels of training were asked to think aloud while either diagnosing or managing a case and to recall the case afterwards.
The present study demonstrated that residents identified more management items than medical students and interns in management focus, which indicates that providing more extensive management plans is a characteristic of developing expertise. The data from interns were also in line with our hypotheses in that they generated significantly more management items when thinking about management than when they were asked to diagnose a clinical case. As expected, the performance of interns was similar to that of residents in terms of the ratio of number of management related items over total items, but with respect to both diagnostic and management accuracy, they resembled less advanced students. Similar to the previous studies, , the management items generated by the interns were generic and blanket, not particularly aimed at managing the specific cases. That is, they wrote a management order without connecting it to the most probable diagnosis. Furthermore, most of the interns' management items were repeated persistently among different protocols, while some highly important and crucial aspects of patient management plan were missed (e.g., in the comatose patients, they asked for routine blood tests like complete blood count or serum electrolytes, but ignored ordering blood glucose level and coma cocktail, which included dextrose, flumazenil, naloxone, and thiamine). This could be indicative of a weak connection between their diagnostic and management knowledge-bases, as expected. Medical students, in contrast, were very persistent and insensitive to the focus. When medical students were asked to deal with a management task, they shifted to a focus they were familiar with, providing instead merely a diagnosis for the case. The absence of management-items in the medical students' protocols is explained by the assumption that they processed cases in diagnostic and management conditions essentially the same way.
Looking at the rest of the illness script components shows us other possible developmental aspects of the illness script. The proportion of the items related to enabling conditions across seems to also follow the developmental path toward expertise. While the residents produced a significantly smaller proportion of enabling conditions in the management-focus, the difference in interns was merely borderline, and negligible in less advanced students. This could provide us with clues for further research into the nature of management-diagnostic knowledge integration during the course of the illness script development.
The strength of this study is in using the thinking aloud method in a different way. By asking participants to think aloud before starting the main task, we made sure that our participants were on the right mode of thinking (diagnostic or management). As for limitations, asking medical students and physicians to evaluate written, hypothetical cases may not fully reflect the situations doctors actually encounter in their practices and the considerations that subjects reported in this study may not reflect their thoughts in actual practice. It is, therefore, possible that certain differences between physicians and students (specifically advanced medical students) might have not been detected.
| Conclusions|| |
This study provides some preliminary evidence that the concept of illness script can be applied to medical encounters that include diagnosis and management, and that expertise research should be extended to cover both domains. Although it demonstrates that management-knowledge may be involved in identifying and describing differences between expertise levels, determining the way management knowledge can be effectively passed on to medical students will be a major challenge for future research. Based on the present and previous studies, it seems that students might benefit from being exposed more to the management side of the medical practice.
| References|| |
|1.||Ericsson KA. An expert-performance perspective of research on medical expertise: the study of clinical performance. Med Educ 2007;41:1124-30. |
|2.||Norman G. Research in clinical reasoning: Past history and current trends. Med Educ 2005;39:418-27. |
|3.||Schmidt HG, Rikers RM. How expertise develops in medicine: Knowledge encapsulation and illness script formation. Med Educ 2007;41:1133-9. |
|4.||Boshuizen HP, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn Sci 1992;16:153-84. |
|5.||Eva KW, Norman GR, Neville AJ, Wood TJ, Brooks LR. Expert/novice differences in memory: A reformulation. Teach Learn Med 2002;14:257-63. |
|6.||Norman GR, Brooks LR, Allen SW. Recall by experts and novices as arecord of processing attention. J Exp Psychol 1989;15:1166-74. |
|7.||Patel VL, Groen GJ, Arocha JF. Medical expertise as a function of task difficulty. Mem Cognit 1990;18:394-406. |
|8.||Schmidt HG, Boshuizen HP. On the origin of intermediate effects in clinical case recall. Mem Cognit 1993;21:338-51. |
|9.||McGuire CH. Medical problem solving: A critique of the literature. J Med Educ 1985;60:587-95. |
|10.||Monajemi A, Rikers RM, Schmidt HG. Clinical case processing: A diagnostic versus a management focus. Med Educ 2007;41: 1166-72. |
|11.||Monajemi A, Rikers RM. The role of patient management knowledge in medical expertise development: Extending the contemporary theory. Int J Pers Cent Med 2011;1:109-14. |
|12.||Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:70-81. |
|13.||Gruppen LD, Frohna AZ. Clinical reasoning. In: Norman GR, van der Vleuten CP, Newble DI, editors. International Handbook of Research in Medical Education. Dordrecht: Kluwer Academic Publishers; 2002. p. 205-30. |
|14.||Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine, New York: Oxford University Press; 2006. |
|15.||Albert M, Hodges B, Regehr G. Research in medical education: balancing service and science. Adv Health Sci Educ Theory Pract 2007;12 :103-15. |
|16.||Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: Theory and implications. Acad Med 1990;65:611-21. |
|17.||Feltovich PJ, Barrows HS. Issues of generality in medical problem solving. In: Schmidt HG, De Volder ML, editors. Tutorials in problem based learning. Assen, The Netherlands: Van Gorcum; 1984. |
|18.||Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ 2007;41:1178-84. |
|19.||Custers EJ, Boshuizen HP, Schmidt HG. The influence of medical expertise, case typicality, and illness script component on case processing and disease probability estimates. Mem Cognit 1996;24:384-99. |
|20.||Custers EJ, Boshuizen HP, Schmidt HG. The role of illness scripts in the development of medical diagnostic expertise: Results from an interview study. Cogn Instr 1998;16:367-98. |
|21.||Patel VL, Groen GJ. Knowledge based solution strategies in medical reasoning. Cogn Sci 1986;10:91-116. |
|22.||Van Someren MW, Barnard YF, Sandberg JA. The think aloud method:A practical guide to modeling cognitive processes, London: Academic Press; 1994. |
|23.||Rikers RM, Schmidt HG, Boshuizen HP. Knowledge encapsulation and the intermediate effect. Contemp Educ Psychol 2000;25:150-66. |
|24.||Rikers RM, Schmidt HG, Boshuizen HP. On the constraints of encapsulated knowledge: Clinical case representation by medical experts and subexperts. Cogn Instr 2002;20:27-45. |
|25.||Monajemi A, Schmidt HG, Rikers RM. Assessing patient management plans of doctors and medical students: An Illness script perspective. J Contin Educ Health Prof 2012;32:4-9. |
|26.||Patel VL, Groen GJ, Patel YC. Cognitive aspects of clinical performance during patient workup: the role of medical expertise. Adv Health Sci Educ 1997;2:95-114. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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