Schubert, C., Denmark, K., Crandall, B., Grome, A., and Pappas, J. (2012). "Characterizing novice-expert differences in macrocognition: An exploratory study of cognitive work in the Emergency Department."Annals of Emergency Medicine
( 10/2012 )
ABSTRACT Study objectives The objectives of this study were to elicit and document descriptions of Emergency Department (ED) physician expertise, to characterize cognitive differences between novice and expert physicians, and to identify areas where novices’ skill and knowledge gaps are most pronounced. The nature of the differences between novices and experts need to be explored in order to develop effective instructional modalities that accelerate the learning curve of inexperienced physicians who work in high complexity environments. Methods We interviewed novice emergency medicine physicians (first-year residents) and attending physicians with significant expertise working in an academic level-one trauma center in Southern California. Using Cognitive Task Analysis (CTA), we employed task diagrams to capture non-routine critical incidents that required the use of complex cognitive skills. Time-lines were constructed to develop a detailed understanding of challenging incidents and the decisions involved as the incident unfolded, followed by progressive deepening to tease out situation specific cues, knowledge, and information that experts and novices used. A thematic analysis of the interview transcripts was conducted to identify key categories. Using classification techniques for data reduction, we identified a smaller set of key themes, which comprised the core findings of the study. Results Five interns and six attending physicians participated in the interviews. Novice physicians reported having difficulties representing the patient’s story to attendings and other health care providers. Over-relying on objective data, novice physicians use linear thinking to move to diagnosis quickly and are likely to discount and explain away data that do not “fit” the frame. Experienced physicians draw on previous expertise to recognize cues and patterns while leaving room for altering or even changing their initial diagnosis. While experts maintain high levels of spatial, temporal, and organizational systems awareness when overseeing treatment modalities of multiple patients, novices have difficulty seeing and maintaining the “big picture.” Conclusion Novice physicians employ sense-making styles that differ from those of experts. Training novices to respond to the high cognitive demand of complex environments early on in their careers requires instructional modalities that not only increase their knowledge base, but accelerate the integration of knowledge and practice. Simulation and custom designed avatar mediated virtual worlds are a promising new technology that may facilitate such training. Future research should expand on the results of this study using a larger sample size and conducting interviews at multiple sites to increase generalizability.