Testing the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce diagnostic error in trauma triage: a study protocol for a randomized pilot trial
Tóm tắt
Non-compliance with clinical practice guidelines in trauma remains common, in part because physicians make diagnostic errors when triaging injured patients. Deliberate practice, purposeful participation in a training task under the oversight of a coach, effectively changes behavior in procedural domains of medicine but has rarely been used to improve diagnostic skill. We plan a pilot parallel randomized trial to test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce physician diagnostic errors in trauma triage. We will randomize a national convenience sample of physicians who work at non-trauma centers (n = 60) in a 1:1 ratio to a deliberate practice intervention or to a passive control. We will use a customized, theory-based serious video game as the basis of our training task, selected based on its behavior change techniques and game mechanics, along with a coaching manual to standardize the fidelity of the intervention delivery. The intervention consists of three 30-min sessions with content experts (coaches), conducted remotely, during which physicians (trainees) play the game and receive feedback on their diagnostic processes. We will assess (a) the fidelity with which the intervention is delivered by reviewing video recordings of the coaching sessions; (b) the acceptability of the intervention through surveys and semi-structured interviews, and (c) the effect of the intervention by comparing the performance of trainees and a control group of physicians on a validated virtual simulation. We hypothesize that trainees will make ≥ 25% fewer diagnostic errors on the simulation than control physicians, a large effect size. We additionally hypothesize that ≥ 90% of trainees will receive their intervention as planned. The results of the trial will inform the decision to proceed with a future hybrid effectiveness-implementation trial of the intervention. It will also provide a deeper understanding of the challenges of using deliberate practice to modify the diagnostic skill of physicians. Clinical trials.gov (
NCT05168579
); 23 December 2021.
Tài liệu tham khảo
US Department of Health and Human Services. Model Trauma System Planning and Evaluation. https://www.hsdl.org/?view&did=463554. Published Feb 2006. Accessed 28 Dec 2021.
American Trauma Society. Trauma Center Levels Explained. https://www.amtrauma.org/page/traumalevels. Accessed 27 Sept 2020.
Committee on Trauma – American College of Surgeons. Resources for optimal care of the injured patient 2006. Chicago: American College of Surgeons; 2006.
American College of Surgeons – Committee on Trauma. Advanced Trauma Life Support for Doctors: Student Course Manual. Chicago: American College of Surgeons; 2020.
Delgado MK, Yokell MA, Staudenmayer KL, et al. Factors associated with the disposition of severely injured patients initially seen at non-trauma center emergency departments. JAMA Surg. 2014;149:422–30.
Zhou Q, Rosengart MR, Billiar TR, et al. Factors associated with non-transfer in trauma patients meeting American College of Surgeons’ criteria for transfer at nontertiary centers. JAMA Surg. 2017;152:369–76.
Mohan D, Rosengart MR, Farris C, et al. Assessing the feasibility of the American College of Surgeons’ benchmarks for the triage of trauma patients. Arch Surg. 2011;146:786–92.
Mohan D, Barnato AE, Rosengart MR, et al. Triage patterns of patients with moderate-to-severe injuries presenting to non-trauma centers. Ann Surg. 2015;261:383–9.
Mohan D, Barnato AE, Angus DC, et al. Determinants of compliance with transfer guidelines for trauma patients: a retrospective analysis of CT scans acquired prior to transfer to a level I trauma center. Ann Surg. 2010;251:946–51.
Mohan D, Rosengart MR, Farris C, et al. Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science study. Implement Sci. 2012;7:103.
Mohan D, Angus DC, Ricketts D, et al. Assessing the validity of using serious game technology to analyze physician decision making. PLoS One. 2014;9:e105445.
Kahneman D, Frederick S. Representativeness revisited: attribute substitution in intuitive judgment. In: Gilovich T, Griffin D, Kahneman D, editors. Heuristics and Biases: The Psychology of Intuitive Judgment. New York: Cambridge University Press; 2002.
Kulkarni K, Dewitt B, Fischhoff B, et al. Defining the representativeness heuristic in trauma triage: a retrospective observational cohort study. PLoS One. 2019;14:e021220.
Mohan D, Farris C, Fischhoff B, et al. Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: a randomized clinical trial. BMJ. 2017;359:j5416.
Mohan D, Fischhoff B, Angus DC, et al. Using serious video games to improve physicians’ heuristics in trauma triage: a randomized clinical trial. PNAS. 2018;115:9204–9.
Onken LS, Carroll KM, Shoham V, et al. Re-envisioning clinical science: unifying the discipline to improve public health. Clin Psychol Sci. 2014;2:22–34.
Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70–81.
Ericsson A, Pool R. Peak: secrets from the new science of expertise. Boston: Houghton Mifflin Harcourt; 2017.
Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406.
McGaghie WC, Issenberg SB, Cohen ER, et al. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86:706–11.
Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol. 2003;58:697–720.
Badjulnour RE, Parsons AS, Muller D, et al. Deliberate practice at the virtual bedside to improve clinical reasoning. NEJM. 2022. https://doi.org/10.1056/NEJMe2204540.
Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Admin Pol Ment Health. 2011;38:65–76.
Moran S, Bereby-Meyer Y, Bazerman M. Stretching the effectiveness of analogical training in negotiations: teaching diverse principles for creating value. Negot Confl Manag Res. 2008;1:99–134.
Michie S, Richardson M, Johnston M, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46:81–95.
Perski O, Blandford A, West R, et al. Conceptualizing engagement with digital behavior change interventions: a systematic review using principles from critical interpretive synthesis. TBM. 2017;7:254–67.
Lemov D. The coach's guide to teaching. Clearfield: John Catt Educational Ltd; 2020.
Lemov D. Teach like a champion 3.0. Hoboken: Jossey-Bass; 2021.
Hoffman TC, Glasziou PP, Milne R. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014:348. https://doi.org/10.1136/bmj.g1687.
Vande Walle KA, Pavaluri Quame SR, Beasley HL, et al. Development and assessment of the Wisconsin Surgical Coaching Rubric. JAMA Surg. 2020;155:486–92.
O’Brien HL, Cairns P, Hall M. A practical approach to measuring user engagement with the refined user engagement scale (UES) and the new UES short form. Int J Hum Comput Stud. 2018;112:28–39.
Cohen J. Quantitative methods in psychology: a power primer. Psychol Bull. 1992;112(1):155–9.
American College of Surgeons. About Advanced Trauma Life Support. https://www.facs.org/quality-programs/trauma/atls/about. Accessed 26 Sept 2020.
Sanfey AG, Loewenstein G, McClure SM, et al. Neuroeconomics: cross-currents in research on decision making. Trends Cogn Sci. 2006;10:108–16.
Mohammad A, Branicki F, Abu-Zidan FM. Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses: a systematic review. World J Surg. 2014;28:322–9.
Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64:515–26.
Mohan D, Chang CC, Fischhoff B, et al. Outcomes after a digital behavior change intervention to improve trauma triage: an analysis of Medicare claims. J Surg Res. 2021;268:532–9.
McGlynn EA, Schneider EC, Kerr EA. Reimagining quality measurement. NEJM. 2014;371:2150–1.
National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington DC: The National Academies Press; 2015.
Bellg AJ, Resnick B, Minicucci DS, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23:443–51.
Ritchie MJ, Parker LE, Kirchner JE. From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery. Implement Sci Commun. 2021;2:39.
Collins L. Optimization of behavioral, biobehavioral, and biomedical interventions: the multiphase optimization strategy (MOST). New York City: Springer Nature; 2018.