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Cognition of Shared Decision Making: The Case of Multiple Sclerosis

Lippa, Katherine Domjan
http://orcid.org/0000-0002-1383-3365
http://rave.ohiolink.edu/etdc/view?acc_num=wright1463576554

Abstract Details

2016, Doctor of Philosophy (PhD), Wright State University, Human Factors and Industrial/Organizational Psychology PhD.
The increasing emphasis in the medical community on shared decision making and patient centered care suggests that patients play a role in their care, but research on clinical reasoning almost exclusively addresses practitioner cognition. As patient involvement increases, it is important to understand the effect patients have on clinical cognition. This necessitates moving beyond a model that equates clinical cognition with practitioner cognition to incorporate the influence of patient cognition and dyadic patient-practitioner cognition. In this dissertation, I suggest that patient-practitioner interactions constitute a distributed cognitive system. As a result patient cognition and the nature of the interaction inherently contribute to clinical cognition. By analyzing different aspects of clinical interactions involved in managing Multiple Sclerosis (MS), I provide an exploratory observational study of how patient-practitioner dyads engage in clinical cognition that may serve as a guide to more conventional future hypothesis testing. To assess clinical interactions, I observed twenty-three patients interacting with three medical practitioners at a clinic specializing in the chronic disease of Multiple Sclerosis. Consistent with Institutional Review Board review, patients agreed to observations of their clinical session including audio recording and/or taking field notes and participated in follow-up phone interviews. Analysis employed techniques from grounded theory, task analysis, and discourse analysis. The results comprise four separate analyses focusing on different aspects of patient-practitioner cognition outlining the core functions of MS management, the fundamental role of the patient in the reconceptualization of management as a distributed task, the effect of patient expertise on clinical reasoning and the role of narrative in facilitating the exchange of information. Specifically, in the first analysis, I decompose the interactions involved in MS management into a series of core functions each of which depends upon different cognitive elements. I analyze the contributions of patients and practitioners to each of these tasks showing that patients and practitioners engage in distributed cognition during all major tasks except interpretation of technical test results. Across the clinical session, practitioners and patients collaborate to create a common trajectory that guides clinical reasoning. The second analysis focuses specifically on the patterns of patient and practitioner responsibility during decision making. To execute the range of decision making tasks, participants navigate through a decision space that includes situational understanding (the state space) and possible actions (the action space). While making decisions, practitioners and patients can each exert control over different constituent tasks, creating four patterns for distributed decision making: practitioner dominated, practitioner defined-patient made, patient defined-practitioner made, and patient dominated. The specific pattern used in a given decision depends upon the access patients and practitioners have to different portions of the decision space. As practitioners and patients navigate through the decision space, they negotiate shared decisions as inflection points in the process of creating a common trajectory for clinical cognition and care. The third analysis examines the effect of patient expertise in MS self-management on distributed clinical cognition. I first demonstrate that patients vary in their level of medical expertise in the management of a chronic disease such as MS. Experienced patients actively constructed representations of clinically relevant experience and presented initial evaluations for the practitioner to refine and validate. By contrast, conversations between newly diagnosed patients and practitioners demonstrated the practitioner’s working to establish a common understanding of the problem space and acceptable interventions. Because of this difference in patient expertise, practitioners must adapt their clinical cognition and mode of interacting. The existence of this adaptation supports my argument that the conceptualization of clinical cognition is fundamentally distributed. The fourth analysis looks at the role of linguistic representation, especially narrative representation, as fundamental to the exchange of information in distributed clinical cognition. Narratives support cognition through attention, memory, and reasoning processes during practitioner-patient interactions. Narrative representations extended access to clinically relevant information by providing specific information about circumstances, subjective experiences, functional capacities of the patient, and prior decision processes. In addition, the hermeneutic nature of narrative supported reasoning, allowing collaborative hypothesis testing. Results across all four analyses supported an interpretation of clinical cognition as an integrated, ongoing process, distributed among patients and practitioners and supported by linguistic representation. Instead of isolated sequential choice points, analyses indicated that the major tasks involved in clinical reasoning are non-sequential and mutually determining, reflecting standard issues in cognition such as problem detection, representation, categorization and causal reasoning. Practitioners and patients each contribute to this trajectory of clinical cognition. Because patients and practitioners inherently have widely different perspectives distributed clinical cognition depends upon the actors’ abilities to represent and integrate divergent conceptualizations of the clinical problem space. As such, language provides an essential medium for distributed clinical cognition.
Valerie Shalin, Ph.D. (Advisor)
Helen Klein, Ph.D. (Committee Member)
Mary Ellen Bargerhuff, Ph.D. (Committee Member)
Debra Steele-Johnson, Ph.D. (Committee Member)
325 p.
Cognitive Psychology; Communication; Health Care; Psychology
Decision Making; Cognition; Doctor-Patient Interaction; Human Factors Psychology; Medical Decision Making; Shared Decision Making; Distributed Cognition; Narrative

Recommended Citations

Citations

  • Lippa, K. D. (2016). Cognition of Shared Decision Making: The Case of Multiple Sclerosis [Doctoral dissertation, Wright State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=wright1463576554

    APA Style (7th edition)

  • Lippa, Katherine. Cognition of Shared Decision Making: The Case of Multiple Sclerosis. 2016. Wright State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=wright1463576554.

    MLA Style (8th edition)

  • Lippa, Katherine. " Cognition of Shared Decision Making: The Case of Multiple Sclerosis." Doctoral dissertation, Wright State University, 2016. http://rave.ohiolink.edu/etdc/view?acc_num=wright1463576554

    Chicago Manual of Style (17th edition)

wright1463576554
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© 2016, all rights reserved.
This open access ETD is published by Wright State University and OhioLINK.