Epistemic cognition in medical education: a literature review.

OBJECTIVE: To review the research literature on epistemic cognition in medical education. METHODS: We conducted database searches using keywords related to epistemic cognition and medical education or practice. In duplicate, authors selected and reviewed empirical studies with a central focus on epistemic cognition and participant samples including medical students or physicians. Independent thematic analysis and consensus procedures were used to identify major findings about epistemic cognition and implications for research and medical education. RESULTS: Twenty-seven articles were selected. Themes from the findings of selected studies included developmental frameworks of epistemic cognition revealing simple epistemological positions of medical learners, increasing epistemological sophistication with experience, relationships between epistemic cognition and context, patterns in epistemic orientations to clinical practice, and reactions to ambiguity and uncertainty. Many studies identified the need for new instruments and methodologies to study epistemic cognition in medical education settings and its relationship to clinical outcomes. Relationships between epistemological beliefs and humanistic patient care and influences of medical education practices were commonly cited implications for medical education. CONCLUSIONS: Epistemic cognition is conceptualized and operationalized in a variety of ways in the medical research literature. Advancing theoretical frameworks and developing new methodological approaches to examine epistemic cognition are important areas for future research. Also, examination of the relationship between the contexts of medical learning and practice and epistemic cognition has potential for improving medical education. This work also establishes a need for further investigation into the implications of epistemic cognition for humanistic orientations and ultimately for patient care.

The search for reasons in a unified relationship.

The paternalism, autonomy debate was influenced by traditional ideas that reasons are either objective (based on values existing independent of any particular person) or subjective (based on values tied to individual's personal histories). This dichotomy has been rewarding for the health care community. However, the tenets of this debate have influenced the nature of deliberation in a way that seriously compromises the ability of health care professionals and patients to bring reflection (the search for justified reasons) to a successful end. It sets up the moral landscape not as one of unity and reciprocity, but as one of divisiveness and distance-where one person (the physician) does something to another (paternalism) or for another (patient autonomy), rather than with another. This distance and divisiveness undermines the unity of wills and genuine reciprocity that I argue is indispensable for genuinely good relationships and necessary for successfully establishing what reasons there are to act. It has created an abyss in communication that even recent suggestions for change cannot bridge. In this paper, I discuss the nature of this abyss and the problems it has created by demonstrating that traditional theoretical ideas about the nature of reasons have influenced the nature of deliberation in health care. I argue that recent suggestions for "justified paternalism" fail to bridge the abyss. Finally, I suggest that to be successful, we must change the framework; we must reject the ideas of objective and subjective value and embrace instead the idea that values are intersubjective.

Research misconduct and the scientific process: continuing quality improvement.

The response to research misconduct involves the attempt to regulate behavior through (a) creating and enforcing a rule and (b) ethics education. The roles of each must be shaped by considerations of the nature of scientific practice. Given the nature of science, the role of (a) must be limited in scope: both in the types of behavior it covers and in the level of intent that must be present for an allegation of misconduct to be proven. Since one important role of ethics education is to fill the gaps that regulatory rules leave open, it is this limitation in scope and its source in theoretical concerns that better reveals the type and kind of education needed. It is argued that much of the current ethics education falls short. Since the gaps left by the rule are largely due to theoretical concerns about the very nature of the scientific process and the nature of that process is constantly evolving, ethics education must focus more heavily on theory and must reach a wider audience. It is argued that ethics education can be more effective if it aims, in part, in creating a discipline-specific, constantly evolving standard of care.