On context specificity and management reasoning: moving beyond diagnosis

James G. Boyle; Matthew R. Walters; Fiona M. Burton; Catherine Paton; Martin Hughes; Susan Jamieson; Steven J. Durning

doi:10.1515/dx-2024-0122

Article

On context specificity and management reasoning: moving beyond diagnosis

James G. Boyle , Matthew R. Walters , Fiona M. Burton , Catherine Paton , Martin Hughes , Susan Jamieson and Steven J. Durning

Published/Copyright: January 8, 2025

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From the journal Diagnosis Volume 12 Issue 2

Abstract

Objectives

Diagnostic error is a global emergency. Context specificity is likely a source of the alarming rate of error and refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and examination findings, but due to the presence of contextual factors, decides on two different diagnoses. Studies have not empirically addressed the potential role of context specificity in management reasoning and errors with a diagnosis may not consistently translate to actual patient care.

Methods

We investigated the effect of context specificity on management reasoning in individuals working within a simulated internal medicine environment. Participants completed two ten minute back to back common encounters. The clinical content of each encounter was identical. One encounter featured the presence of carefully controlled contextual factors (CF+ vs. CF−) designed to distract from the correct diagnosis and management. Immediately after each encounter participants completed a post encounter form.

Results

Twenty senior medical students participated. The leading diagnosis score was higher (mean 0.88; SEM 0.07) for the CF− encounter compared with the CF+ encounter (0.58; 0.1; 95 % CI 0.04–0.56; p=0.02). Management reasoning scores were higher (mean 5.48; SEM 0.66) for the CF− encounter compared with the CF+ encounter (3.5; 0.56; 95 % CI 0.69–3.26; p=0.01). We demonstrated context specificity in both diagnostic and management reasoning.

Conclusions

This study is the first to empirically demonstrate that management reasoning, which directly impacts the patient, is also influenced by context specificity, providing additional evidence of context specificity’s role in unwanted variance in health care.

Keywords: clinical reasoning; context specificity; diagnostic reasoning; management reasoning; distributed cognition; error

Corresponding author: Dr. James G. Boyle, Glasgow Royal Infirmary, School of Medicine, Dentistry and Nursing (SMDN), University of Glasgow, Glasgow, UK, E-mail: james.boyle@glasgow.ac.uk

Acknowledgments

We are greatly indebted to the team at Kirklands Hospital Simulation Centre in Bothwell, Lanarkshire.

Research ethics: College of MVLS, University of Glasgow approved the study. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).
Informed consent: Informed consent was obtained from all individuals included in this study.
Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission. Concept: JB, MRW, SJ, SJD. Design: All. Data collection: JB, FMB, MH, CP. Analysis: JB, MRW, SJ, SJD. Drafting: JB wrote first draft. Critical Review DR: All.
Use of Large Language Models, AI and Machine Learning Tools: None declared.
Conflict of interest: The authors state no conflict of interest.
Research funding: None declared.
Data availability: The raw data can be obtained on reasonable request from the corresponding author.
Disclaimer: The views expressed herein are those of the authors and not necessarily those of the Department of Defense or other federal agencies.

Appendix

Controlled content for both CF− and CF+ cases

Case	CF−	CF+
Presentation	Short history dyspnoea and chest pain. Associated with orthopnea, cough without purulent sputum, bilateral ankle swelling, reduced exercise tolerance which worsened with chest pain. Patient uncertain if has lost sense of taste or smell at present as has been off food recently. Pain is both dull (not sharp) and central. Pain feels similar but ‘a bit different’ from previous MI and patient unable to explain why. Patient is certain pain is 7/10 in severity but uncertain if pain feels worse when breathing in or out. Patient feels cold and has a clenched first held over central chest (Levine sign)	Short history dyspnoea and chest pain. Associated with orthopnea, cough without purulent sputum, bilateral ankle swelling, reduced exercise tolerance which worsened with chest pain. Patient uncertain if has lost sense of taste or smell at present as has been off food recently. Pain is both dull (not sharp) and central. Pain feels similar but ‘a bit different’ from previous MI and patient unable to explain why. Patient is certain pain is 7/10 in severity but uncertain if pain feels worse when breathing in or out. Patient feels cold and has a clenched first held over central chest. (Levine’s sign)
PMHx	61 years old with ischaemic heart disease and previous MI, heart failure, hypertension, Type 2 diabetes	63 years old with ischaemic heart disease and previous MI, heart failure, hypertension, Type 2 diabetes
Drug Hx	Aspirin Furosemide Ramipril Metformin Dapagliflozin Atorvastatin NKDA Inconsistent adherence to medication	Aspirin Bumetanide Losartan Metformin Empagliflozin Simvastatin NKDA Inconsistent adherence to medication
SHx	Ex-smoker, alcohol within guidance, retired bus driver, married with children	Ex-smoker, alcohol within guidance, retired teacher, married without children
FHx	Father had ‘heart attack’	Several family members have T2DM
Observations	Apyrexial, tachycardia, hypertensive, oxygen therapy maintains saturations	Apyrexial, tachycardia, hypertensive, oxygen therapy maintains saturations
Examination	Levine’s sign + (see above) Heart sounds normal Bibasal crepitations Bilateral pedal oedema	Levine’s sign + (see above) Heart sounds normal Bibasal crepitations Bilateral pedal oedema
ECG findings	Sinus rhythm and old LBBB	Sinus rhythm and old LBBB

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Received: 2024-07-10

Accepted: 2024-11-30

Published Online: 2025-01-08

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Articles in the same Issue

https://doi.org/10.1515/dx-2024-0122

Keywords for this article

clinical reasoning; context specificity; diagnostic reasoning; management reasoning; distributed cognition; error