Cognitive dissonance: how self-protective distortions can undermine clinical judgement.

Editor’s note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members. This issue of Academic Medicine is devoted to an exciting set of research reports, reviews, and commentaries selected for publication from more than 60 submissions as part of our ongoing collaboration with the Research In Medical Education (RIME) program.1–17 The topics are wide-ranging—experiences of moral distress among trainees, interprofessional team leadership, assessment and feedback during training, and the role of arts and humanities in professional identity formation, to name just a few. As in the past, each of these published articles will be presented and discussed as part of the RIME program at Learn Serve Lead 2024: The AAMC Annual Meeting, which takes place this month. RIME’s work highlights creativity and quality in education scholarship and communicates the importance of medical education inquiry to stakeholders throughout academic medicine, such as institutional leaders, promotions committee members, and learners. RIME articles elevate issues of concern to medical education in a timely manner. Such attention can lead to dialogue, consensus, and advances in the field. RIME also supports the professional development of medical education scholars. Manuscripts submitted for consideration by the RIME Program Planning Committee receive written feedback from reviewers and committee members, and service on the RIME committee itself is a valuable learning experience and opportunity for leadership in medical education and academic medicine. In celebrating RIME’s 60th anniversary in 2021, members of the RIME Program Planning Committee conducted a survey of past RIME chairs to better understand how RIME has helped advance medical education research.18 The past chairs recognized RIME as a catalyst for medical education research, strengthening the rigor and impact of medical education research, developing a community of scholars, and supporting academic career development. They also identified as priorities the need for greater innovation and translation of medical education research to practice. They welcomed new activities and collaborations, such as faculty mentorship initiatives and support for educators pursuing advanced degrees in education.18 Each year leaders on the RIME committee prepare a commentary, published as part of the RIME collection, that addresses a way to improve medical education research in academic medicine. In 2012, RIME leaders called for a more intentional, strategic, and inclusive effort. Medical education research requires an intellectual structure, a framework into which seemingly random studies can come together to improve learning and practice. The challenge before us is to look forward and develop a well-laid plan to further the field of medical education research nationally and internationally.19 For this year’s commentary, Sukhera and colleagues1 similarly challenge the field of academic medicine to do work that will improve learning and practice. They encourage medical education researchers to think beyond rigor, relevance, and utility in their work and to find ways to generate new knowledge that is readily—and will actually be—used. Drawing upon insights from implementation science, the authors call upon medical education researchers to mobilize toward actionable, scalable, impactful scholarship. Over the years, Academic Medicine has partnered with RIME to publish 30 journal supplements; RIME collections have also appeared in our regular issues in October 2012, October 2013, and November 2014. The editorial teams of Academic Medicine and our AAMC sister journal, MedEdPORTAL, have also been fortunate to benefit from the service of members of the RIME community, such as manuscript authors, creators of curricular and education resources, and expert reviewers. Authors of RIME articles have been featured on the Academic Medicine Podcast, which further increases the reach of the scholarly contributions. Academic Medicine also was pleased to collaborate with the leadership of RIME in 2022 when it launched its mentorship program for early and underrepresented faculty scholars, a program that has evolved to become MedEdSCHOLAR.20 This year, we are pleased to feature the RIME articles and commentaries in this issue of Academic Medicine. This decision reflects our continued strong support for the work of the RIME planning committee, RIME authors, and the broader RIME community in furthering medical education scholarship.

University of Missouri—Kansas City School of Medicine

Over recent decades, the use of qualitative methodologies has increased in medical education research. These include ethnographic approaches, which have been used to explore complex cultural norms and phenomena by way of long-term engagement in the field of research. Often, however, medical education consists of short-term episodes that are not bound to single sites, but take place in a myriad of locations and contexts such as classrooms, examination stations, clinical settings and online. This calls for methodologies that allow us to grasp what is at stake in an increasingly multifaceted and diverse field. In this article, we direct attention to focused ethnography, which has emerged as a useful, suitable and feasible applied qualitative research approach, and which uses adapted classic ethnographic methods, such as direct observation, to gain new insights and nuanced understandings of distinct phenomena, themes and interactions in specific settings in medical education (eg the learning potential of ward rounds, or how hierarchical positions affect learning situations). We introduce methodological key features of focused ethnography to give insights into how the approach can be used, and we offer examples of how the method has been used in medical education research to show how it has contributed in different ways to the field of medical education research. Furthermore, we address and discuss some of the main challenges and limitations of the approach. Focused ethnography offers a methodological approach that sheds light over limited and well-defined social episodes and interactions. Precisely because the field of medical education consists to a large degree of such fragmented interactions, focused ethnography can be seen as a methodology tailored to these characteristics and should become an integrated part of the toolkit of medical education research.

COGNITIVE DISSONANCE CHALLENGES A POSSIBILITY OF HUMAN EVOLUTION Cognitive dissonance (CD) is a discomfort caused by holding conflicting elements of knowledge. CD is among “the most influential and extensively studied theories in social psychology” (e.g., Alfnes et al., 2010, p. 147). It is well known that this discomfort is usually resolved by devaluing and discarding a conflicting piece of knowledge (Festinger, 1957; Cooper, 2007; HarmonJones et al., 2009); we discuss it in detail below. It is also known that awareness of CD is not necessary for actions to reduce the conflict, and these actions are often fast and momentary (Jarcho et al., 2011). CD is particularly evident when a new scientific theory is developed. It takes a while to accept the new knowledge. However, I would like to emphasize that even a mundane element of knowledge to be useful it must differ from innate knowledge supplied by evolution or from existing knowledge acquired through experience. Otherwise the new knowledge would not be needed. For new knowledge to be useful it must contradict existing knowledge to some extent. Can new knowledge be complementary rather than contradicting? New knowledge does not come from nowhere, knowledge grows by analogy, by differentiation of previous knowledge, by using what already exists. This is the reason for several empirical laws: Zipf ’s law, the power law, Pareto laws. All of these laws essentially express equivalent statistical properties of systems, in which new entities (or usage) evolve from pre-existing ones (Simonton, 2000; Newman, 2005; Novak, 2010). For example, according to Zipf ’s law the frequency of a word is inversely proportional to its statistical rank; this empirical relation is observed in most languages and in many other similar systems (this was theoretically proven in the given references). Since new knowledge emerges by modifying previous knowledge, there must always be conflict between the two. Because of this conflict between new and previous knowledge CD theory suggests that new knowledge should be discarded. This process of resolving CD by discarding contradictions is usually fast, “momentary” and according to CD theory new knowledge is discarded before its usefulness is established. This is the paradoxical conclusion of CD theory. To summarize, according to CD theory knowledge has to be devalued and discarded. But accumulation of knowledge is the hallmark of human evolution. It follows that the fact of human cultural evolution contradicts this well established theory. This paradoxical aspect of CD has not received appropriate attention during more than 50 years of the development of CD theory.

How and why social science theory can contribute to medical education research

Likert-type scales are frequently used in medical education and medical education research. Common uses include end-of-rotation trainee feedback, faculty evaluations of trainees, and assessment of performance after an educational intervention. A sizable percentage of the educational research manuscripts submitted to the Journal of Graduate Medical Education employ a Likert scale for part or all of the outcome assessments. Thus, understanding the interpretation and analysis of data derived from Likert scales is imperative for those working in medical education and education research. The goal of this article is to provide readers who do not have extensive statistics background with the basics needed to understand these concepts. Developed in 1932 by Rensis Likert1 to measure attitudes, the typical Likert scale is a 5- or 7-point ordinal scale used by respondents to rate the degree to which they agree or disagree with a statement (table). In an ordinal scale, responses can be rated or ranked, but the distance between responses is not measurable. Thus, the differences between “always,” “often,” and “sometimes” on a frequency response Likert scale are not necessarily equal. In other words, one cannot assume that the difference between responses is equidistant even though the numbers assigned to those responses are. This is in contrast to interval data, in which the difference between responses can be calculated and the numbers do refer to a measureable “something.” An example of interval data would be numbers of procedures done per resident: a score of 3 means the resident has conducted 3 procedures. Interestingly, with computer technology, survey designers can create continuous measure scales that do provide interval responses as an alternative to a Likert scale. The various continuous measures for pain are well-known examples of this (figure 1). FIGURE 1 Continuous Measure Example TABLE Typical Likert Scales

Background: The physician–patient relationship is the foundation of health care. As a key component of effective communication, empathy fosters trust and enhances patient outcomes. However, cognitive dissonance arising from conflicts between cognitive and affective empathy (AE) can negatively affect physician well-being, directly impacting the quality of care. This exploratory, correlational, cross-sectional study investigates the relationships between clinical empathy, AE, cognitive empathy (CE), cognitive dissonance, and subjective well-being among physicians. Methods: A purposive snowball sampling technique was employed to collect survey data from 106 physicians registered under the Medical Council of India practicing allopathic medicine, through validated psychometric scales such as the Jefferson Scale of Empathy, Basic Empathy Scale, Cognitive Dissonance Scale, and Well-being Index. Data were analyzed using descriptive statistics, correlation analyses, and nonparametric tests in IBM SPSS 29.0 and mediation, confirmatory factor analysis in Amos 29. Results: Clinical empathy was significantly positively correlated with CE ( r = 0.307, P = 0.001) and AE ( r = 0.232, P = 0.017). AE showed a significant positive correlation with CE ( r = 0.371, P < 0.001). CE was significantly negatively correlated with cognitive dissonance ( r = −0.197, P = 0.043). Cognitive dissonance was significantly negatively correlated with subjective well-being ( r = −0.293, P = 0.002). Conclusion: Findings indicate that higher CE may be associated with lower cognitive dissonance, and that cognitive dissonance is negatively associated with subjective well-being. These findings may inform practical training and support programs for physicians and contribute to advancements in both medical education and the quality of care.

Purpose Based on cognitive dissonance theory and emotional memory linkage theory, this study proposes a serial mediation model of “digital hoarding → cognitive dissonance → emotional memory linkage → nostalgic consumption”, aiming at exploring how digital hoarding can drive individual's nostalgic consumption behaviors through psychological mechanisms. Design/methodology/approach We conducted two scenario experiments to systematically examine these relationships. Experiment 1, which exposed participants to a digital hoarding context through situational manipulation, revealed that digital hoarding significantly and positively predicts nostalgic consumption intention. Experiment 2 introduced scales for cognitive dissonance and emotional memory linkage, with the bootstrap method applied to examine mediating effects. Findings The results showed that digital hoarding significantly increases nostalgic consumption intention. Cognitive dissonance and emotional memory linkage independently mediate this relationship, concurrently forming a sequential pathway where cognitive dissonance activates nostalgic memory retrieval, ultimately amplifying nostalgic consumption desire. Originality/value This study expands the positive value dimensions of digital hoarding research from the interdisciplinary perspective of consumer behavior and psychology, establishes a novel paradigm for understanding emotional compensation mechanisms under technology-induced stress, and provides a theoretical foundation for businesses to design nostalgia-oriented marketing strategies and refine digital asset management tools.

Medical education research in general is a young scientific discipline which is still finding its own position in the scientific range. It is rooted in both the biomedical sciences and the social sciences, each with their own scientific language. A more unique feature of medical education (and assessment) research is that it has to be both locally and internationally relevant. This is not always easy and sometimes leads to purely ideographic descriptions of an assessment procedure with insufficient general lessons or generalised scientific knowledge being generated or vice versa. For medical educational research, a plethora of methodologies is available to cater to many different research questions. This article contains consensus positions and suggestions on various elements of medical education (assessment) research. Overarching is the position that without a good theoretical underpinning and good knowledge of the existing literature, good research and sound conclusions are impossible to produce, and that there is no inherently superior methodology, but that the best methodology is the one most suited to answer the research question unambiguously. Although the positions should not be perceived as dogmas, they should be taken as very serious recommendations. Topics covered are: types of research, theoretical frameworks, designs and methodologies, instrument properties or psychometrics, costs/acceptability, ethics, infrastructure and support.

Given the corporate pursuit of discontinuous and breakthrough change, we work to deconstruct and shed understanding on managers' failure to formally allocate resources to entrepreneurial activities that seek to deliver disruptive innovations. Using an interpretivist approach with field data from two primary and four secondary cases, we show that managers' failure to recognise the restrictive impact of their mental models---their implicitly held images and beliefs---regarding the goals of innovation and organisational development will lead them to reject opportunities with disruptive potential. We design and implement a graphical Portfolio Management intervention to expose and overcome these maladaptive behaviours and find that managers employ up to five different 'disruptive innovation rejection strategies' when innovation opportunities are incongruent with dominant mental models. The rejection strategies are observed to be driven by the psychologically uncomfortable emergence of 'cognitive dissonance'. We further ground the data in the often neglected literature from social psychology's cognitive dissonance theory to generate implications for business leaders, instigating an innovative stream of research for those interested in further enhancing our understanding of the entrepreneurial pursuit of disruptive innovations.

PurposeEmploying cognitive dissonance theory, this study examines how consumers’ preexisting attitudes toward an issue, value involvement with the issue and consumer-company identification (CCI) influence their reactions to corporate social advocacy (CSA) through cognitive dissonance.Design/methodology/approachStudy 1 conducted a 2 (CSA position: pro vs anti) × 3 (preexisting issue attitude: pro vs neutral vs anti) online quasi-experiment. The CSA messages were created in the context of same-sex marriage(s). Study 2 tested the hypotheses using an online survey in the context of gun control.FindingsThe results indicated that a conflict between consumers’ preexisting attitudes and a corporation’s stance on a controversial issue led to cognitive dissonance, which further led to consumers’ perceptions of the corporation being biased in both studies. Study 1 and Study 2 suggested a mixed effect of cognitive dissonance on participants’ inclination to disidentify with the corporation. Preexisting CCI appeared to have a direct negative influence on cognitive dissonance; however, value involvement and preexisting CCI were not found to significantly enhance the influence of consumers’ attitudes toward CSA on cognitive dissonance.Originality/valueThe study first extended the theoretical discussion of cognitive dissonance to a trendy strategic communication context. The results help public relations practitioners to better understand the segmented public groups and the risk of taking a stance on controversial issues.

BackgroundEvidence supports peer learning in clinical settings, but it has not been studied in obstetric units. In Sweden, obstetric units are a challenging learning area for student midwives because of the lack of attention to student needs and the stress of attaining the final number of 50 assisted births. ObjectivesTo explore how student midwives experienced peer learning during clinical placement in an obstetric unit. DesignQualitative approach. SettingsThree hospitals and obstetric units in Stockholm, Sweden. ParticipantsFifteen student midwives in a peer-learning model during clinical placement. MethodsIndividual interviews followed by deductive content analysis using Boud's (2001) theoretical descriptions of peer learning. ResultsThe students shared skills, experience, and knowledge as equals and took responsibility for their peers' learning while supporting women in labor and childbirth. Students shared ideas, thoughts, and knowledge and gained perspective while learning as peers on an equal level. Students used each other to work independently without much involvement from the preceptor. Feedback was welcomed as encouragement. ConclusionsPeer learning had positive consequences as an educational model in the clinical context in obstetric units.

Emory University School of Medicine.

Medical education research faces increasing pressure to demonstrate impact and utility. These pressures arise amidst a climate of accountability and within a culture of outcome measurement. Conventional metrics for assessing research impact such as citation analysis have been adopted in medical education, despite researchers' assertion that these quantitative measures insufficiently reflect the value of their work. Every knowledge community has its own definitions of what counts as knowledge, how that knowledge should be produced, and how the quality of that knowledge production should be evaluated. Definitions of impact and knowledge shape and constrain researchers' foci and endeavors. Therefore, metrics that meaningfully evaluate the knowledge outputs of researchers need to be defined within each field. It is time for medical education research, as a field, to examine how to measure research impact and carefully consider the broader implications these measures may have. The authors discuss developments in research metrics more broadly, then critically examine impact metrics currently used in the medical education field and propose alternatives to more meaningfully track and represent impact in medical education research. Grey metrics and narrative impact stories to more fully capture the richness and nuanced nature of impact in medical education research are introduced. The authors advocate for a continual examination of how impact is defined, eschewing unquestioned use of conventional metrics. A new conversation is needed, as well as a research agenda to help medical education conceptualize and study metrics more appropriate for the field.

Objective and Aim The growing emphasis on accountability, quality assurance, and outcomes-based education has intensified the demand for robust and critically appraised evidence in medical education. While the principles of evidence-based medicine have substantially shaped clinical decision-making, their direct transfer to educational contexts has proven conceptually and methodologically challenging. Objective: This systematic review aims to synthesize the literature on evidence types, critical appraisal frameworks, and methodological quality standards in medical education research, and to present an integrative appraisal matrix suitable for educational decision-making. Methods A systematic review was conducted in accordance with PRISMA 2020 guidelines (7). Searches were performed in MEDLINE (PubMed), ERIC, Scopus, and Web of Science for studies published between 2000 and 2024. Included studies addressed evidence hierarchies, critical appraisal, research quality instruments, or methodological frameworks in medical or health professions education. Data were synthesized narratively due to methodological heterogeneity. Results Eighty-four studies met inclusion criteria. Evidence in medical education was categorized into quantitative, qualitative, mixed-methods, and design-based research. Traditional biomedical hierarchies were insufficient to capture educational relevance and contextual complexity. Appraisal tools such as BEME, MERSQI, CASP, and realist review frameworks were commonly cited, yet inconsistently applied. Conclusions Critical appraisal in medical education requires a pluralistic, theory-informed, and context-sensitive approach. The proposed appraisal matrix integrates methodological rigor, educational relevance, outcomes meaningfulness, and transferability to support informed educational practice. Keywords: Medical education research; Systematic review; Critical appraisal; Evidence hierarchy; Research methodology