Medical Decision Making in the Physician Hierarchy: A Pilot Pedagogical Evaluation

Context: Recently, The American College of Graduate Medical Education (ACGME) has included the medical decision making as a core competency in several specialties. To date, the ability to demonstrate and measure a pedagogical evolution of medical judgment in a medical education program has been limited. Objective: In this study we hope to examine differences in medical decision making ability of different physicians across their various stages of post-graduate hierarchy. Method: Physcians spanning a wide spectrum of scientific disciplines were recruited for three catagories: administrative physicians(AP) representing physcians with the most experience but mostly practice administratively; resident physicians completing their postgraduate medical training (RP) and seasoned attending physicians with mastery level experience (MP). Participants completed four medical simulations focused on abdominal pain: cholecystitis (CH) and renal colic(RC) and chest pain; Cardiac ischemia (STEMI) and pneumothorax (PX). Simulation were ordered randomly so that there was no systematic bias due to learning or to fatigue. The Medical judgment metric (MJM) was used to evaluate medical decision-making. Results: There were no significant differences between the AP, RP, and MP groups in the gender, race, ethnicity, education, and baseline heart rate. There was a significant (p=0.002) interaction effect for simulation time and RP group, 6.2 minutes (+/-1.58); MP group, 8.7 minutes (+/-2.46); and AP group, 10.3 minutes (+/-2.78). The RC MJM scores were significantly (P=0.10) worse in the AP group 12.3 (+/-2.66) then the RP 14.7(+/-1.15) and MP17.7 (+/-1.15) groups. In every simulation, the AP group MJM scores were worse on average (no significantly) compared to the MP and RP groups. The AP group was significantly (P=0.040) less likely to stabilize the subject in the RC simulation than MP and RP groups. Conclusion: There remains significant variability in the medical education and skill retention influences medical decision making throughout a physician's career.