Opening the Black Box: Cognitive Strategies in Family Practice

Christensen, Fetters, and Green (2005) report their use of Cognitive Task Analysis (Militello & Hutton, 1998) to describe 18 individual physicians’ ways of organizing their visits with patients. One of their findings is wonderful, but another just makes me wonder.

Through analysis of these structured qualitative interviews, they were able to identify 5 distinct approaches that family physicians use for dealing with a patient’s presenting symptoms and prevention needs. This gives concrete and specific content to the notion that individual physicians follow different scripts with their patients (Hamm, 2003; Schmidt, Norman, & Boshuizen, 1990). Clearly it is important to know about the variety of these approaches. In particular, those hoping to improve physicians’ behavior, for example to increase the rate at which they recognize and use opportunities to deliver preventive medicine interventions, must consider generally (a) what is required to alter behavior that is embedded in a script of this sort, and more specifically (b) whether different interventions are necessary for physicians who use different approaches. The Cognitive Task Analysis methodology differs from any approach that fits every individual into a single a priori structure, because it constructs an appropriate representation of how each individual handles the task. It is also an improvement over the unstructured qualitative approach we used in Surgical Scripts (Abernathy & Hamm, 1994), which transcribed whatever the physician said when a case was presented.

I wonder, however, about another of the results that Christensen, Fetters, and Green (2005) report. They state that in their repeated conversations about the elaborated transcripts of the 18 interviews, some themes emerged. The third theme was,

“...the characteristic features of expert decision making, especially the automaticity and attentional surplus exhibited by expert family physicians. Automaticity refers to the effect achieved by years of practice and expertise wherein basic elements of the task are performed largely without conscious awareness, and attentional surplus refers to reserve capacity to handle additional problems in a given decision-making setting—in this case, during the patient encounter.”

I am fully with them in thinking that experts’ automatic processing of the situation allows them some attentional surplus, and that that surplus can help them recognize opportunities for preventive interventions that the struggling beginner does not notice. Indeed in Surgical Intuition (Abernathy & Hamm, 1995) we spent 10 pages (114-124) arguing that this is an important mechanism of experts’ superior intuitive performance. The problem is that I don’t see any connection between the interview data and this theme. If I didn’t trust the authors, or I didn’t already believe in the theme, there would not be any reason for me to accept the conclusion.

The method builds on what the physician says about how he or she usually deals with a type of situation. The only available measure of the physicians’ expertise was years of experience. Perhaps automaticity could be inferred from the absence of detail in the interview. But the paper did not report any correlations between years of experience and absence of detail. Instead, the reader is asked to accept that as the 3 authors mulled over the 18 transcripts, the relation between expertise and automaticity crystallized in their minds. It is even harder to imagine the basis for the second proposition, which is the relation between the degree to which the physician had automatized the management of routine patient encounters, and the availability of spare working memory capacity or attentional surplus that manifests itself in additional ability to notice the opportunity for preventive interventions, and flexible responding. Since the interview did not involve the physician responding to a patient, how could this superior noticing ability and flexible responding be seen? Did the experts self-report that they were better at it? Or did the less experienced physicians self-report that they were deficient in it? The third proposition of this interesting theme is that the expert physicians’ attentional surplus produces better performance. Again, how was this causal link established? And how would the authors reconcile this with the recent claim that more experienced physicians actually perform less well (Choudhry, Fletcher, & Soumerai, 2005)?

In conclusion, this paper is on an important topic, the method can produce novel insights, the authors share with me an interest in the advantages of experts’ automaticized cognitive processing, and I would love to hear more details about how they used their method to study the concept of attentional surplus.

Abernathy, C. M., & Hamm, R. M. (1994). Surgical Scripts. Philadelphia, PA: Hanley and Belfus.

Abernathy, C. M., & Hamm, R. M. (1995). Surgical Intuition. Philadelphia, PA: Hanley and Belfus.

Choudhry, N. K., Fletcher, R. H., & Soumerai, S. B. (2005). Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med, 142(4), 260-273.

Christensen, R. E., Fetters, M. D., & Green, L. A. (2005). Opening the black box: cognitive strategies in family practice. Ann Fam Med, 3(2), 144-150.

Hamm, R. M. (2003). Medical decision scripts: Combining cognitive scripts and judgment strategies to account fully for medical decision making. In D. Hardman & L. Macchi (Eds.), Thinking: Psychological Perspectives on Reasoning, Judgment and Decision Making (pp. 315-345). Chichester, West Sussex, GB: John Wiley & Sons, Ltd.

Militello, L. G., & Hutton, R. J. (1998). Applied cognitive task analysis (ACTA): A practitioner's toolkit for understanding cognitive task demands. Ergonomics, 41, 1618-1641.

Schmidt, H. G., Norman, G. R., & Boshuizen, H. P. (1990). A cognitive perspective on medical expertise: theory and implication. Acad Med, 65(10), 611-621.

Competing interests:   None declared