Abstract:
Introduction:
Medical teams constantly work with patients in critical conditions and complex environments. Within these environments, it is understood that cognitive, metacognitive and affective processes coexist, promoting or preventing an adequate performance11. Brydges R, Butler D. A reflective analysis of medical education research on self-regulation in learning and practice. Med Educ. 2012;46:71-9.),(22. Zimmerman BJ, Schunk DH, organizadores. Handbook of self-regulation of learning and performance. New York: Routledge; 2011. 484 p.. In this study, a case of medical misdiagnosis is analyzed from a metacognitive perspective.
Objectives:
1- Describe the thinking processes that led to the misdiagnosis, 2- Investigate possible contributions of metacognitive processes to medical education.
Methods:
Group interview33. Flick U. Entrevistas. In: Caregnato SE, organizador. Uma introdução à pesquisa qualitativa. 3a ed Porto Alegre: Bookman; 2009. p. 143-79. with the winning team of a simulation contest for attending critical patients held at a national medical education congress. Content analysis44. Bardin L. Análise de conteúdo. 3a reimp. São Paulo: Edições 70; 2011. v. 1, 280 p., coded by Atlas-ti™, according to Efklides55. Efklides A. Metacognition-defining its facets and levels of functioning in relation to self-regulation and co-regulation. Eur Psychol. 2008;13(4):277-87., followed by the extraction of empirical categories in the SimpleMind™ Mind Map Editor. The study was registered (CAAE 96007018.5.0000.5286) and approved (Opinion No. 2,938,945) by the Research Ethics Committee of Institute of Collective Health Studies at the Federal University of Rio de Janeiro.
Results:
Before the contest, the team predicted possible scenarios. During the contest, the simulated scenario presented to the participants was similar to one of the previously predicted scenarios. It was then observed that the team unconsciously biased all their reasoning aiming to confirm the previously predicted diagnosis. Different metacognitive mechanisms involved in this process are described. The team had sufficient knowledge to establish the correct diagnosis but did not do it due to the distortion of their thinking processes. This case illustrates the fact that, to practice medicine, knowledge is not enough; learning to think is also necessary. In addition, a proposal for a theoretical framework is established, where the simulation presents itself as a problematizing methodology, providing a context where metacognition and the Maguerez Arch66. Tsuji H, da Silva H. A. Aprender e ensinar na escola vestida de branco: do modelo biomédico ao humanístico. São Paulo: Phorte; 2010. 240 p. are harmoniously integrated with Ausubel’s Meaningful Learning Theory77. Ausubel DP. Educational psychology: a cognitive view. New York. Holt, Rinehart and Winston; 1968. 685 p.),(88. Moreira MA. Aprendizagem significativa: a teoria e textos complementares. São Paulo: Livraria da Física; 2011. 179 p. for professional competence66. Tsuji H, da Silva H. A. Aprender e ensinar na escola vestida de branco: do modelo biomédico ao humanístico. São Paulo: Phorte; 2010. 240 p. development.
Conclusions:
It is concluded that metacognition can elucidate events such as those described here, also suggesting that its teaching and practice could contribute to the reduction in medical misdiagnosis.
Keywords:
Metacognition; Learning; Students; Simulation Training; Diagnostic Errors; Clinical Decision-Making
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