Stephen Folger

Associate Professor

Physical Therapy Education

Elon University

There is a significant body of work that has begun to elucidate clinical decision making differences between beginner and expert clinicians in physical therapy and other health professions.1,2 Several key principles which characterize novice-expert differences appear to cut across many disciplines (e.g. education).2,3 Understanding how expert clinicians approach a clinical problem, collect data, and arrive at a specific diagnosis and intervention is powerful information for educators as we help usher our students toward this level of clinical skill.

Over the years, I have observed that many educators often teach behind a mental podium. There is a lack of full disclosure of the mental gymnastics that occurs as we think through a problem. We often fail to teach explicitly and instead leave critical information in an implied state that is easily missed or misunderstood. The “black box” remains closed unless the student asks a specific question to shed light on the details. I believe this mainly occurs because the process or journey to an answer becomes so “second nature” to us that we project the clarity onto the students; thinking that they understand it and move on to the next topic.

Similarly, our students remain behind mental desks and, unless prompted, rarely provide any details on how they arrived at a certain answer. The journey to the answer is just as important as arriving at the best answer.4 Assessing the outcome only (i.e. right or wrong decision) does not clarify why a poor choice was made or capture errors in judgment that were resolved before the end of the task.5 The purpose of this proposal is to shine a spot light into the proverbial “black box” to illuminate the entire clinical decision making process so that the path is clear to both the student and instructor.

Situation awareness (SA) is a model that has a long history in military applications and, in particular, pilot training. Endsley defines situation awareness as “the perception of the elements in the environment within a volume of space and time, the comprehension of their meaning, and the projection of their status in the near future”. 5

This model describes three distinct levels of SA:

• Level 1: Perception of information (“what are the important facts?”),
• Level 2: Comprehension (“what is happening?”) and
• Level 3: Projecting into the future (forecasting “what if” scenarios).5,6

Situation Awareness

The ability of a pilot to take in all available information from the instrument panel and body senses, process it and select the appropriate response can mean the difference between survival and death. Likewise, an emergency room doctor needs to have situation awareness to select the best form of care for their critically ill patient. Ignoring important information (e.g. symptoms) or not comprehending their meaning can lead to tragic results in both examples. Investigations of situation awareness in human factors research attempt to understand how individuals collect relevant facts, comprehend the situation and then forecast future events.

The aviation and emergency room examples have a strong time component that requires split second decisions with high stake outcomes. Clearly, most medical situations do not require immediate decisions and therefore, operate on a longer time scale. Can the situation awareness model be used to study these clinical decision making processes? I believe the answer to this question is yes, and the same tools that are used to measure situation awareness with pilots can be adapted to study the clinical decision making process of physical therapy students.

Singh et al 6 argue that the SA model can be applied to medical decision making and provides an innovative way to study the diagnostic process toward preventing diagnostic errors. The authors use a clinical case example to illustrate how the SA framework can be used to identify times of reduced situation awareness leading to errors in clinical judgment. Interestingly, the case and associated clinical decisions unfold over a time scale of months suggesting that the SA model is applicable to physical therapy. Although Singh et al6 select a narrowly focused outcome measure, diagnostic error; it does support the application of this model in medical fields and provides a foundation for an expanded assessment of the efficacy of the decision making process and outcomes.

There are several tools for measuring situation awareness. In physical therapy education we often use a post-activity debriefing interview to have the student recall what they were thinking during the activity. The problem with this method is the potential for poor recall or hindsight bias diminishing the accuracy of the information. 6 The Situation Awareness Global Assessment Technique (SAGAT) is a commonly used and validated method which periodically stops the participant to ask specific questions to assess their SA in each of the 3 levels.5,6,7,8 For example, during a real or simulated patient examination, the student would be periodically stopped and queried on their understanding of the patient problem and confidence level. The periodic SA probes do not significantly impact performance and mitigate the effects of poor recall and hindsight bias.5,6,8 At the completion of the examination process, the student and instructor have a clear roadmap of how the student arrived at their final clinical decisions and potential faulty reasoning along the way. An extension of this level of clarity could be computer training modules that are customized for the student to work on a specific component of SA.5

Case studies are commonly used in physical therapy education because of their value in teaching clinical decision making without patient risk. Web-based case studies, a program I developed with Dr. Bill Andrews, provide more individualized scenarios and feedback than paper-based cases, making them more realistic and simulating higher levels of patient care decision-making.9 The student directs an online examination or intervention by selectively choosing tests or interventions from a comprehensive list. The entire process is tracked by recording each selection and answer in a database. This enables educators to evaluate and possibly follow the development of clinical judgment skills by individual students by tracking performance across multiple cases; 9 however, the reasoning behind the clinical decisions during each case remains hidden.

This proposal combines a brand new approach to physical therapy education with the web-based case study platform to expose the journey to a clinical decision. To this end, the SAGAT approach will be used to periodically stop the student and assess their level of situation awareness and confidence during each case. In addition an online tool will be developed to allow the instructor to assess individual and group performance during the case and provide feedback to the student(s).

Specific Aims:
Year 1
1. Modify the current web-based case study program to measure situation awareness based on the Situation Awareness Global Assessment Technique (SAGAT).
2. Add 10 complete cases with SA probes.
3. Develop an assessment tool to evaluate the effectiveness of the SAGAT/web-case approach.
4. Host focus group discussions with students and faculty on assessing decision making, SA enhanced web-cases and the potential for generalizing the approach to other disciplines.
Year 2
1. Add 10 more complete cases with SA probes.
2. Implement the use of these cases in several courses in the DPT curriculum.
3. Assessment: Compare web cases with SA probes to regular web cases and traditional paper cases.
4. Present this work on campus and at regional, national or international conferences.