Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study.

PubMed

Lee, JuHee; Lee, Young Joo; Bae, JuYeon; Seo, Minjeong

2016-11-01

As complex chronic diseases are increasing, nurses' prompt and accurate clinical reasoning skills are essential. However, little is known about the reasoning skills of registered nurses. This study aimed to determine how registered nurses use their clinical reasoning skills and to identify how the reasoning process proceeds in the complex clinical situation of hospital setting. A qualitative exploratory design was used with a think-aloud method. A total of 13 registered nurses (mean years of experience=11.4) participated in the study, solving an ill-structured clinical problem based on complex chronic patients cases in a hospital setting. Data were analyzed using deductive content analysis. Findings showed that the registered nurses used a variety of clinical reasoning skills. The most commonly used skill was 'checking accuracy and reliability.' The reasoning process of registered nurses covered assessment, analysis, diagnosis, planning/implementation, and evaluation phase. It is critical that registered nurses apply appropriate clinical reasoning skills in complex clinical practice. The main focus of registered nurses' reasoning in this study was assessing a patient's health problem, and their reasoning process was cyclic, rather than linear. There is a need for educational strategy development to enhance registered nurses' competency in determining appropriate interventions in a timely and accurate fashion. Copyright © 2016 Elsevier Ltd. All rights reserved.

What variables can influence clinical reasoning?

PubMed

Ashoorion, Vahid; Liaghatdar, Mohammad Javad; Adibi, Peyman

2012-12-01

Clinical reasoning is one of the most important competencies that a physician should achieve. Many medical schools and licensing bodies try to predict it based on some general measures such as critical thinking, personality, and emotional intelligence. This study aimed at providing a model to design the relationship between the constructs. Sixty-nine medical students participated in this study. A battery test devised that consist four parts: Clinical reasoning measures, personality NEO inventory, Bar-On EQ inventory, and California critical thinking questionnaire. All participants completed the tests. Correlation and multiple regression analysis consumed for data analysis. There is low to moderate correlations between clinical reasoning and other variables. Emotional intelligence is the only variable that contributes clinical reasoning construct (r=0.17-0.34) (R(2) chnage = 0.46, P Value = 0.000). Although, clinical reasoning can be considered as a kind of thinking, no significant correlation detected between it and other constructs. Emotional intelligence (and its subscales) is the only variable that can be used for clinical reasoning prediction.

How does questioning influence nursing students' clinical reasoning in problem-based learning? A scoping review.

PubMed

Merisier, Sophia; Larue, Caroline; Boyer, Louise

2018-06-01

Problem-based learning is an educational method promoting clinical reasoning that has been implemented in many fields of health education. Questioning is a learning strategy often employed in problem-based learning sessions. To explore what is known about the influence of questioning on the promotion of clinical reasoning of students in health care education, specifically in the field of nursing and using the educational method of problem-based learning. A scoping review following Arksey and O'Malley's five stages was conducted. The CINAHL, EMBASE, ERIC, Medline, and PubMed databases were searched for articles published between the years of 2000 and 2017. Each article was summarized and analyzed using a data extraction sheet in relation to its purpose, population group, setting, methods, and results. A descriptive explication of the studies based on an inductive analysis of their findings to address the aim of the review was made. Nineteen studies were included in the analysis. The studies explored the influence of questioning on critical thinking rather than on clinical reasoning. The nature of the questions asked and the effect of higher-order questions on critical thinking were the most commonly occurring themes. Few studies addressed the use of questioning in problem-based learning. More empirical evidence is needed to gain a better understanding of the benefit of questioning in problem-based learning to promote students' clinical reasoning. Copyright © 2018 Elsevier Ltd. All rights reserved.

CNTRO: A Semantic Web Ontology for Temporal Relation Inferencing in Clinical Narratives.

PubMed

Tao, Cui; Wei, Wei-Qi; Solbrig, Harold R; Savova, Guergana; Chute, Christopher G

2010-11-13

Using Semantic-Web specifications to represent temporal information in clinical narratives is an important step for temporal reasoning and answering time-oriented queries. Existing temporal models are either not compatible with the powerful reasoning tools developed for the Semantic Web, or designed only for structured clinical data and therefore are not ready to be applied on natural-language-based clinical narrative reports directly. We have developed a Semantic-Web ontology which is called Clinical Narrative Temporal Relation ontology. Using this ontology, temporal information in clinical narratives can be represented as RDF (Resource Description Framework) triples. More temporal information and relations can then be inferred by Semantic-Web based reasoning tools. Experimental results show that this ontology can represent temporal information in real clinical narratives successfully.

Emotional reasoning and parent-based reasoning in non-clinical children, and their prospective relationships with anxiety symptoms.

PubMed

Morren, Mattijn; Muris, Peter; Kindt, Merel; Schouten, Erik; van den Hout, Marcel

2008-12-01

Emotional and parent-based reasoning refer to the tendency to rely on personal or parental anxiety response information rather than on objective danger information when estimating the dangerousness of a situation. This study investigated the prospective relationships of emotional and parent-based reasoning with anxiety symptoms in a sample of non-clinical children aged 8-14 years (n = 122). Children completed the anxiety subscales of the Revised Children's Anxiety and Depression Scale (Muris et al. Clin Psychol Psychother 9:430-442, 2002) and provided danger ratings of scenarios that systematically combined objective danger and objective safety information with anxiety-response and positive-response information. These measurements were repeated 10 months later (range 8-11 months). Emotional and parent-based reasoning effects emerged on both occasions. In addition, both effects were modestly stable, but only in case of objective safety. Evidence was found that initial anxiety levels were positively related to emotional reasoning 10 months later. In addition, initial levels of emotional reasoning were positively related to anxiety at a later time, but only when age was taken into account. That is, this relationship changed with increasing age from positive to negative. No significant prospective relationships emerged between anxiety and parent-based reasoning. As yet the clinical implications of these findings are limited, although preliminary evidence indicates that interpretation bias can be modified to decrease anxiety.

Emotional Reasoning and Parent-Based Reasoning in Non-Clinical Children, and Their Prospective Relationships with Anxiety Symptoms

ERIC Educational Resources Information Center

Morren, Mattijn; Muris, Peter; Kindt, Merel; Schouten, Erik; van den Hout, Marcel

2008-01-01

Emotional and parent-based reasoning refer to the tendency to rely on personal or parental anxiety response information rather than on objective danger information when estimating the dangerousness of a situation. This study investigated the prospective relationships of emotional and parent-based reasoning with anxiety symptoms in a sample of…

A comprehensive test of clinical reasoning for medical students: An olympiad experience in Iran

PubMed Central

Monajemi, Alireza; Arabshahi, Kamran Soltani; Soltani, Akbar; Arbabi, Farshid; Akbari, Roghieh; Custers, Eugene; Hadadgar, Arash; Hadizadeh, Fatemeh; Changiz, Tahereh; Adibi, Peyman

2012-01-01

Background: Although some tests for clinical reasoning assessment are now available, the theories of medical expertise have not played a major role in this filed. In this paper, illness script theory was chose as a theoretical framework and contemporary clinical reasoning tests were put together based on this theoretical model. Materials and Methods: This paper is a qualitative study performed with an action research approach. This style of research is performed in a context where authorities focus on promoting their organizations’ performance and is carried out in the form of teamwork called participatory research. Results: Results are presented in four parts as basic concepts, clinical reasoning assessment, test framework, and scoring. Conclusion: we concluded that no single test could thoroughly assess clinical reasoning competency, and therefore a battery of clinical reasoning tests is needed. This battery should cover all three parts of clinical reasoning process: script activation, selection and verification. In addition, not only both analytical and non-analytical reasoning, but also both diagnostic and management reasoning should evenly take into consideration in this battery. This paper explains the process of designing and implementing the battery of clinical reasoning in the Olympiad for medical sciences students through an action research. PMID:23555113

Working memory, reasoning, and expertise in medicine-insights into their relationship using functional neuroimaging.

PubMed

Hruska, Pam; Krigolson, Olav; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Hecker, Kent G

2016-12-01

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.

Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators.

PubMed

Delany, Clare; Golding, Clinton

2014-01-30

Clinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students. Twenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student's reasoning skills. Data included participants' written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning. Two overriding themes emerged from participants' reports about using the 'making thinking visible approach'. The first was a specific focus by participating educators on students' understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning. We suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators

PubMed Central

2014-01-01

Background Clinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students. Methods Twenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. Data included participants’ written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning. Results Two overriding themes emerged from participants’ reports about using the ‘making thinking visible approach’. The first was a specific focus by participating educators on students’ understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning. Conclusions We suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use. PMID:24479414

Pharmacogenomic knowledge representation, reasoning and genome-based clinical decision support based on OWL 2 DL ontologies.

PubMed

Samwald, Matthias; Miñarro Giménez, Jose Antonio; Boyce, Richard D; Freimuth, Robert R; Adlassnig, Klaus-Peter; Dumontier, Michel

2015-02-22

Every year, hundreds of thousands of patients experience treatment failure or adverse drug reactions (ADRs), many of which could be prevented by pharmacogenomic testing. However, the primary knowledge needed for clinical pharmacogenomics is currently dispersed over disparate data structures and captured in unstructured or semi-structured formalizations. This is a source of potential ambiguity and complexity, making it difficult to create reliable information technology systems for enabling clinical pharmacogenomics. We developed Web Ontology Language (OWL) ontologies and automated reasoning methodologies to meet the following goals: 1) provide a simple and concise formalism for representing pharmacogenomic knowledge, 2) finde errors and insufficient definitions in pharmacogenomic knowledge bases, 3) automatically assign alleles and phenotypes to patients, 4) match patients to clinically appropriate pharmacogenomic guidelines and clinical decision support messages and 5) facilitate the detection of inconsistencies and overlaps between pharmacogenomic treatment guidelines from different sources. We evaluated different reasoning systems and test our approach with a large collection of publicly available genetic profiles. Our methodology proved to be a novel and useful choice for representing, analyzing and using pharmacogenomic data. The Genomic Clinical Decision Support (Genomic CDS) ontology represents 336 SNPs with 707 variants; 665 haplotypes related to 43 genes; 22 rules related to drug-response phenotypes; and 308 clinical decision support rules. OWL reasoning identified CDS rules with overlapping target populations but differing treatment recommendations. Only a modest number of clinical decision support rules were triggered for a collection of 943 public genetic profiles. We found significant performance differences across available OWL reasoners. The ontology-based framework we developed can be used to represent, organize and reason over the growing wealth of pharmacogenomic knowledge, as well as to identify errors, inconsistencies and insufficient definitions in source data sets or individual patient data. Our study highlights both advantages and potential practical issues with such an ontology-based approach.

Simulation-Based Dysphagia Training: Teaching Interprofessional Clinical Reasoning in a Hospital Environment.

PubMed

Miles, Anna; Friary, Philippa; Jackson, Bianca; Sekula, Julia; Braakhuis, Andrea

2016-06-01

This study evaluated hospital readiness and interprofessional clinical reasoning in speech-language pathology and dietetics students following a simulation-based teaching package. Thirty-one students participated in two half-day simulation workshops. The training included orientation to the hospital setting, part-task skill learning and immersive simulated cases. Students completed workshop evaluation forms. They filled in a 10-question survey regarding confidence, knowledge and preparedness for working in a hospital environment before and immediately after the workshops. Students completed written 15-min clinical vignettes at 1 month prior to training, immediately prior to training and immediately after training. A marking rubric was devised to evaluate the responses to the clinical vignettes within a framework of interprofessional education. The simulation workshops were well received by all students. There was a significant increase in students' self-ratings of confidence, preparedness and knowledge following the study day (p < .001). There was a significant increase in student overall scores in clinical vignettes after training with the greatest increase in clinical reasoning (p < .001). Interprofessional simulation-based training has benefits in developing hospital readiness and clinical reasoning in allied health students.

[Teaching of clinical reasoning to medical students using prototypical clinical cases].

PubMed

Montaldo L, Gustavo; Herskovic L, Pedro

2013-07-01

Clinical reasoning is the most important competente in the training process of a physician. To develop a method for teaching clinical reasoning based on prototypes of clinical cases. The study was conducted on sixty-four third year medical students. The study and control groups attended lectures and tutorial sessions with patients. The study group attended additionally discussion seminars of prototypical clinical cases. A clinical reasoning test was applied at the start and end of the learning period to both groups. At the end of the study, the opinions of students of the study group were collected in a focus group. After the learning period, both groups significantly increased their clinical reasoning skills. However, the improvement in the study group was more than double than that of the control group. The absolute improvement in the study group was 30.9%. Students interviewed in the focus group were unanimous in expressing their satisfaction in each and every aspect discussed. The teaching of clinical reasoning to third year medical students by means of pattern recognition in seminars with clinical cases improved significantly their skills.

Semantics-based plausible reasoning to extend the knowledge coverage of medical knowledge bases for improved clinical decision support.

PubMed

Mohammadhassanzadeh, Hossein; Van Woensel, William; Abidi, Samina Raza; Abidi, Syed Sibte Raza

2017-01-01

Capturing complete medical knowledge is challenging-often due to incomplete patient Electronic Health Records (EHR), but also because of valuable, tacit medical knowledge hidden away in physicians' experiences. To extend the coverage of incomplete medical knowledge-based systems beyond their deductive closure, and thus enhance their decision-support capabilities, we argue that innovative, multi-strategy reasoning approaches should be applied. In particular, plausible reasoning mechanisms apply patterns from human thought processes, such as generalization, similarity and interpolation, based on attributional, hierarchical, and relational knowledge. Plausible reasoning mechanisms include inductive reasoning , which generalizes the commonalities among the data to induce new rules, and analogical reasoning , which is guided by data similarities to infer new facts. By further leveraging rich, biomedical Semantic Web ontologies to represent medical knowledge, both known and tentative, we increase the accuracy and expressivity of plausible reasoning, and cope with issues such as data heterogeneity, inconsistency and interoperability. In this paper, we present a Semantic Web-based, multi-strategy reasoning approach, which integrates deductive and plausible reasoning and exploits Semantic Web technology to solve complex clinical decision support queries. We evaluated our system using a real-world medical dataset of patients with hepatitis, from which we randomly removed different percentages of data (5%, 10%, 15%, and 20%) to reflect scenarios with increasing amounts of incomplete medical knowledge. To increase the reliability of the results, we generated 5 independent datasets for each percentage of missing values, which resulted in 20 experimental datasets (in addition to the original dataset). The results show that plausibly inferred knowledge extends the coverage of the knowledge base by, on average, 2%, 7%, 12%, and 16% for datasets with, respectively, 5%, 10%, 15%, and 20% of missing values. This expansion in the KB coverage allowed solving complex disease diagnostic queries that were previously unresolvable, without losing the correctness of the answers. However, compared to deductive reasoning, data-intensive plausible reasoning mechanisms yield a significant performance overhead. We observed that plausible reasoning approaches, by generating tentative inferences and leveraging domain knowledge of experts, allow us to extend the coverage of medical knowledge bases, resulting in improved clinical decision support. Second, by leveraging OWL ontological knowledge, we are able to increase the expressivity and accuracy of plausible reasoning methods. Third, our approach is applicable to clinical decision support systems for a range of chronic diseases.

Do Expert Clinical Teachers Have a Shared Understanding of What Constitutes a Competent Reasoning Performance in Case-Based Teaching?

ERIC Educational Resources Information Center

Gauthier, Geneviève; Lajoie, Susanne P.

2014-01-01

To explore the assessment challenge related to case based learning we study how experienced clinical teachers--i.e., those who regularly teach and assess case-based learning--conceptualize the notion of competent reasoning performance for specific teaching cases. Through an in-depth qualitative case study of five expert teachers, we investigate…

What variables can influence clinical reasoning?

PubMed Central

Ashoorion, Vahid; Liaghatdar, Mohammad Javad; Adibi, Peyman

2012-01-01

Background: Clinical reasoning is one of the most important competencies that a physician should achieve. Many medical schools and licensing bodies try to predict it based on some general measures such as critical thinking, personality, and emotional intelligence. This study aimed at providing a model to design the relationship between the constructs. Materials and Methods: Sixty-nine medical students participated in this study. A battery test devised that consist four parts: Clinical reasoning measures, personality NEO inventory, Bar-On EQ inventory, and California critical thinking questionnaire. All participants completed the tests. Correlation and multiple regression analysis consumed for data analysis. Results: There is low to moderate correlations between clinical reasoning and other variables. Emotional intelligence is the only variable that contributes clinical reasoning construct (r=0.17-0.34) (R2 chnage = 0.46, P Value = 0.000). Conclusion: Although, clinical reasoning can be considered as a kind of thinking, no significant correlation detected between it and other constructs. Emotional intelligence (and its subscales) is the only variable that can be used for clinical reasoning prediction. PMID:23853636

Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors.

PubMed

Vaughan-Graham, Julie; Cott, Cheryl

2017-10-01

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept. A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive. Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group. This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas. © 2016 John Wiley & Sons, Ltd.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review.

PubMed

Maissan, Francois; Pool, Jan; de Raaij, Edwin; Mollema, Jürgen; Ostelo, Raymond; Wittink, Harriet

2018-06-01

Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias. Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016. RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included. Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)]. Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2. In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process. Copyright © 2018 Elsevier Ltd. All rights reserved.

Conveying Clinical Reasoning Based on Visual Observation via Eye-Movement Modelling Examples

ERIC Educational Resources Information Center

Jarodzka, Halszka; Balslev, Thomas; Holmqvist, Kenneth; Nystrom, Marcus; Scheiter, Katharina; Gerjets, Peter; Eika, Berit

2012-01-01

Complex perceptual tasks, like clinical reasoning based on visual observations of patients, require not only conceptual knowledge about diagnostic classes but also the skills to visually search for symptoms and interpret these observations. However, medical education so far has focused very little on how visual observation skills can be…

Generic Reflective Feedback: An Effective Approach to Developing Clinical Reasoning Skills

ERIC Educational Resources Information Center

Wojcikowski, K.; Brownie, S.

2013-01-01

Problem-based learning can be an effective tool to develop clinical reasoning skills. However, it traditionally takes place in tutorial groups, giving students little flexibility in how and when they learn. This pilot study compared the effectiveness of generic reflective feedback (GRF) with tutorial-based reflective feedback on the development of…

Development of the Computerized Model of Performance-Based Measurement System to Measure Nurses' Clinical Competence.

PubMed

Liou, Shwu-Ru; Liu, Hsiu-Chen; Tsai, Shu-Ling; Cheng, Ching-Yu; Yu, Wei-Chieh; Chu, Tsui-Ping

2016-04-01

Critical thinking skills and clinical competence are for providing quality patient care. The purpose of this study is to develop the Computerized Model of Performance-Based Measurement system based on the Clinical Reasoning Model. The system can evaluate and identify learning needs for clinical competency and be used as a learning tool to increase clinical competency by using computers. The system includes 10 high-risk, high-volume clinical case scenarios coupled with questions testing clinical reasoning, interpersonal, and technical skills. Questions were sequenced to reflect patients' changing condition and arranged by following the process of collecting and managing information, diagnosing and differentiating urgency of problems, and solving problems. The content validity and known-groups validity was established. The Kuder-Richardson Formula 20 was 0.90 and test-retest reliability was supported (r = 0.78). Nursing educators can use the system to understand students' needs for achieving clinical competence, and therefore, educational plans can be made to better prepare students and facilitate their smooth transition to a future clinical environment. Clinical nurses can use the system to evaluate their performance-based abilities and weakness in clinical reasoning. Appropriate training programs can be designed and implemented to practically promote nurses' clinical competence and quality of patient care.

Advancing clinical reasoning in virtual patients - development and application of a conceptual framework.

PubMed

Hege, Inga; Kononowicz, Andrzej A; Berman, Norman B; Lenzer, Benedikt; Kiesewetter, Jan

2018-01-01

Background: Clinical reasoning is a complex skill students have to acquire during their education. For educators it is difficult to explain their reasoning to students, because it is partly an automatic and unconscious process. Virtual Patients (VPs) are used to support the acquisition of clinical reasoning skills in healthcare education. However, until now it remains unclear which features or settings of VPs optimally foster clinical reasoning. Therefore, our aims were to identify key concepts of the clinical reasoning process in a qualitative approach and draw conclusions on how each concept can be enhanced to advance the learning of clinical reasoning with virtual patients. Methods: We chose a grounded theory approach to identify key categories and concepts of learning clinical reasoning and develop a framework. Throughout this process, the emerging codes were discussed with a panel of interdisciplinary experts. In a second step we applied the framework to virtual patients. Results: Based on the data we identified the core category as the "multifactorial nature of learning clinical reasoning". This category is reflected in the following five main categories: Psychological Theories, Patient-centeredness, Context, Learner-centeredness, and Teaching/Assessment. Each category encompasses between four and six related concepts. Conclusions: With our approach we were able to elaborate how key categories and concepts of clinical reasoning can be applied to virtual patients. This includes aspects such as allowing learners to access a large number of VPs with adaptable levels of complexity and feedback or emphasizing dual processing, errors, and uncertainty.

Advancing clinical reasoning in virtual patients – development and application of a conceptual framework

PubMed Central

Hege, Inga; Kononowicz, Andrzej A.; Berman, Norman B.; Lenzer, Benedikt; Kiesewetter, Jan

2018-01-01

Background: Clinical reasoning is a complex skill students have to acquire during their education. For educators it is difficult to explain their reasoning to students, because it is partly an automatic and unconscious process. Virtual Patients (VPs) are used to support the acquisition of clinical reasoning skills in healthcare education. However, until now it remains unclear which features or settings of VPs optimally foster clinical reasoning. Therefore, our aims were to identify key concepts of the clinical reasoning process in a qualitative approach and draw conclusions on how each concept can be enhanced to advance the learning of clinical reasoning with virtual patients. Methods: We chose a grounded theory approach to identify key categories and concepts of learning clinical reasoning and develop a framework. Throughout this process, the emerging codes were discussed with a panel of interdisciplinary experts. In a second step we applied the framework to virtual patients. Results: Based on the data we identified the core category as the "multifactorial nature of learning clinical reasoning". This category is reflected in the following five main categories: Psychological Theories, Patient-centeredness, Context, Learner-centeredness, and Teaching/Assessment. Each category encompasses between four and six related concepts. Conclusions: With our approach we were able to elaborate how key categories and concepts of clinical reasoning can be applied to virtual patients. This includes aspects such as allowing learners to access a large number of VPs with adaptable levels of complexity and feedback or emphasizing dual processing, errors, and uncertainty. PMID:29497697

Bringing explicit insight into cognitive psychology features during clinical reasoning seminars: a prospective, controlled study.

PubMed

Nendaz, Mathieu R; Gut, Anne M; Louis-Simonet, Martine; Perrier, Arnaud; Vu, Nu V

2011-04-01

Facets of reasoning competence influenced by an explicit insight into cognitive psychology features during clinical reasoning seminars have not been specifically explored. This prospective, controlled study, conducted at the University of Geneva Faculty of Medicine, Switzerland, assessed the impact on sixth-year medical students' patient work-up of case-based reasoning seminars, bringing them explicit insight into cognitive aspects of their reasoning. Volunteer students registered for our three-month Internal Medicine elective were assigned to one of two training conditions: standard (control) or modified (intervention) case-based reasoning seminars. These seminars start with the patient's presenting complaint and the students must ask the tutor for additional clinical information to progress through case resolution. For this intervention, the tutors made each step explicit to students and encouraged self-reflection on their reasoning processes. At the end of their elective, students' performances were assessed through encounters with two standardized patients and chart write-ups. Twenty-nine students participated, providing a total of 58 encounters. The overall differences in accuracy of the final diagnosis given to the patient at the end of the encounter (control 63% vs intervention 74%, p = 0.53) and of the final diagnosis mentioned in the patient chart (61% vs 70%, p = 0.58) were not statistically significant. The students in the intervention group significantly more often listed the correct diagnosis among the differential diagnoses in their charts (75% vs 97%, p = 0.02). This case-based clinical reasoning seminar intervention, designed to bring students insight into cognitive features of their reasoning, improved aspects of diagnostic competence.

Virtual Patient Simulations for Medical Education: Increasing Clinical Reasoning Skills through Deliberate Practice

ERIC Educational Resources Information Center

McCoy, Lise

2014-01-01

Virtual Patient Simulations (VPS) are web-based exercises involving simulated patients in virtual environments. This study investigates the utility of VPS for increasing medical student clinical reasoning skills, collaboration, and engagement. Many studies indicate that VPS provide medical students with essential practice in clinical decision…

Articular dysfunction patterns in patients with mechanical low back pain: A clinical algorithm to guide specific mobilization and manipulation techniques.

PubMed

Dewitte, V; Cagnie, B; Barbe, T; Beernaert, A; Vanthillo, B; Danneels, L

2015-06-01

Recent systematic reviews have demonstrated reasonable evidence that lumbar mobilization and manipulation techniques are beneficial. However, knowledge on optimal techniques and doses, and its clinical reasoning is currently lacking. To address this, a clinical algorithm is presented so as to guide therapists in their clinical reasoning to identify patients who are likely to respond to lumbar mobilization and/or manipulation and to direct appropriate technique selection. Key features in subjective and clinical examination suggestive of mechanical nociceptive pain probably arising from articular structures, can categorize patients into distinct articular dysfunction patterns. Based on these patterns, specific mobilization and manipulation techniques are suggested. This clinical algorithm is merely based on empirical clinical expertise and complemented through knowledge exchange between international colleagues. The added value of the proposed articular dysfunction patterns should be considered within a broader perspective. Copyright © 2014 Elsevier Ltd. All rights reserved.

Terminated Trials in the ClinicalTrials.gov Results Database: Evaluation of Availability of Primary Outcome Data and Reasons for Termination

PubMed Central

Williams, Rebecca J.; Tse, Tony; DiPiazza, Katelyn; Zarin, Deborah A.

2015-01-01

Background Clinical trials that end prematurely (or “terminate”) raise financial, ethical, and scientific concerns. The extent to which the results of such trials are disseminated and the reasons for termination have not been well characterized. Methods and Findings A cross-sectional, descriptive study of terminated clinical trials posted on the ClinicalTrials.gov results database as of February 2013 was conducted. The main outcomes were to characterize the availability of primary outcome data on ClinicalTrials.gov and in the published literature and to identify the reasons for trial termination. Approximately 12% of trials with results posted on the ClinicalTrials.gov results database (905/7,646) were terminated. Most trials were terminated for reasons other than accumulated data from the trial (68%; 619/905), with an insufficient rate of accrual being the lead reason for termination among these trials (57%; 350/619). Of the remaining trials, 21% (193/905) were terminated based on data from the trial (findings of efficacy or toxicity) and 10% (93/905) did not specify a reason. Overall, data for a primary outcome measure were available on ClinicalTrials.gov and in the published literature for 72% (648/905) and 22% (198/905) of trials, respectively. Primary outcome data were reported on the ClinicalTrials.gov results database and in the published literature more frequently (91% and 46%, respectively) when the decision to terminate was based on data from the trial. Conclusions Trials terminate for a variety of reasons, not all of which reflect failures in the process or an inability to achieve the intended goals. Primary outcome data were reported most often when termination was based on data from the trial. Further research is needed to identify best practices for disseminating the experience and data resulting from terminated trials in order to help ensure maximal societal benefit from the investments of trial participants and others involved with the study. PMID:26011295

Terminated Trials in the ClinicalTrials.gov Results Database: Evaluation of Availability of Primary Outcome Data and Reasons for Termination.

PubMed

Williams, Rebecca J; Tse, Tony; DiPiazza, Katelyn; Zarin, Deborah A

2015-01-01

Clinical trials that end prematurely (or "terminate") raise financial, ethical, and scientific concerns. The extent to which the results of such trials are disseminated and the reasons for termination have not been well characterized. A cross-sectional, descriptive study of terminated clinical trials posted on the ClinicalTrials.gov results database as of February 2013 was conducted. The main outcomes were to characterize the availability of primary outcome data on ClinicalTrials.gov and in the published literature and to identify the reasons for trial termination. Approximately 12% of trials with results posted on the ClinicalTrials.gov results database (905/7,646) were terminated. Most trials were terminated for reasons other than accumulated data from the trial (68%; 619/905), with an insufficient rate of accrual being the lead reason for termination among these trials (57%; 350/619). Of the remaining trials, 21% (193/905) were terminated based on data from the trial (findings of efficacy or toxicity) and 10% (93/905) did not specify a reason. Overall, data for a primary outcome measure were available on ClinicalTrials.gov and in the published literature for 72% (648/905) and 22% (198/905) of trials, respectively. Primary outcome data were reported on the ClinicalTrials.gov results database and in the published literature more frequently (91% and 46%, respectively) when the decision to terminate was based on data from the trial. Trials terminate for a variety of reasons, not all of which reflect failures in the process or an inability to achieve the intended goals. Primary outcome data were reported most often when termination was based on data from the trial. Further research is needed to identify best practices for disseminating the experience and data resulting from terminated trials in order to help ensure maximal societal benefit from the investments of trial participants and others involved with the study.

Promoting the self-regulation of clinical reasoning skills in nursing students.

PubMed

Kuiper, R; Pesut, D; Kautz, D

2009-10-02

The purpose of this paper is to describe the research surrounding the theories and models the authors united to describe the essential components of clinical reasoning in nursing practice education. The research was conducted with nursing students in health care settings through the application of teaching and learning strategies with the Self-Regulated Learning Model (SRL) and the Outcome-Present-State-Test (OPT) Model of Reflective Clinical Reasoning. Standardized nursing languages provided the content and clinical vocabulary for the clinical reasoning task. This descriptive study described the application of the OPT model of clinical reasoning, use of nursing language content, and reflective journals based on the SRL model with 66 undergraduate nursing students over an 8 month period of time. The study tested the idea that self-regulation of clinical reasoning skills can be developed using self-regulation theory and the OPT model. This research supports a framework for effective teaching and learning methods to promote and document learner progress in mastering clinical reasoning skills. Self-regulated Learning strategies coupled with the OPT model suggest benefits of self-observation and self-monitoring during clinical reasoning activities, and pinpoints where guidance is needed for the development of cognitive and metacognitive awareness. Thinking and reasoning about the complexities of patient care needs requires attention to the content, processes and outcomes that make a nursing care difference. These principles and concepts are valuable to clinical decision making for nurses globally as they deal with local, regional, national and international health care issues.

Assessing progression of clinical reasoning through virtual patients: An exploratory study.

PubMed

Forsberg, Elenita; Ziegert, Kristina; Hult, Håkan; Fors, Uno

2016-01-01

To avoid test-driven learning, there have been discussions regarding the use of more formative assessments in health care education to promote students' deep learning. Feedback is important in formative assessment, but many students ignore it; therefore, interventions should be introduced which stimulate them to reflect on the new knowledge. The aim for this study was to explore if Virtual Patient (VP)-based formative assessments, in connection with self-evaluations, had an impact on postgraduate pediatric nursing students' development of clinical reasoning abilities. Students' self-evaluations served as the basis for measuring progress. Data was analysed using deductive content analysis. The findings showed a clear progression of the clinical reasoning ability of the students. After the first assessment, the students described feelings of uncertainty and that their knowledge gaps were exposed. At the mid-course assessment the awareness of improved clinical reasoning was obvious and the students were more certain of knowing how to solve the VP cases. In the final assessment, self-efficacy was expressed. VP-based assessments, in connection with self-evaluations, early in the education resulted in a gain of students' own identification of the concept of clinical reasoning, awareness of what to focus on during clinical practice and visualised expected clinical competence. Copyright © 2015 Elsevier Ltd. All rights reserved.

Bardoxolone brings Nrf2-based therapies to light.

PubMed

Zhang, Donna D

2013-08-10

The targeted activation of nuclear factor erythroid-derived-2-like 2 (Nrf2) to alleviate symptoms of chronic kidney disease has recently garnered much attention. Unfortunately, the greatest clinical success to date, bardoxolone, failed in phase III clinical trial for unspecified safety reasons. The present letter to the editor discusses the clinical development of bardoxolone and explores potential reasons for the ultimate withdrawal from clinical trials. In particular, was the correct clinical indication pursued and would improved specificity have mitigated the safety concerns? Ultimately, it is concluded that the right clinical indication and heightened specificity will lead to successful Nrf2-based therapies. Therefore, the bardoxolone clinical results do not dampen enthusiasm for Nrf2-based therapies; rather it illuminates the clinical potential of the Nrf2 pathway as a drug target.

Deterministic versus evidence-based attitude towards clinical diagnosis.

PubMed

Soltani, Akbar; Moayyeri, Alireza

2007-08-01

Generally, two basic classes have been proposed for scientific explanation of events. Deductive reasoning emphasizes on reaching conclusions about a hypothesis based on verification of universal laws pertinent to that hypothesis, while inductive or probabilistic reasoning explains an event by calculation of some probabilities for that event to be related to a given hypothesis. Although both types of reasoning are used in clinical practice, evidence-based medicine stresses on the advantages of the second approach for most instances in medical decision making. While 'probabilistic or evidence-based' reasoning seems to involve more mathematical formulas at the first look, this attitude is more dynamic and less imprisoned by the rigidity of mathematics comparing with 'deterministic or mathematical attitude'. In the field of medical diagnosis, appreciation of uncertainty in clinical encounters and utilization of likelihood ratio as measure of accuracy seem to be the most important characteristics of evidence-based doctors. Other characteristics include use of series of tests for refining probability, changing diagnostic thresholds considering external evidences and nature of the disease, and attention to confidence intervals to estimate uncertainty of research-derived parameters.

Exploring examinee behaviours as validity evidence for multiple-choice question examinations.

PubMed

Surry, Luke T; Torre, Dario; Durning, Steven J

2017-10-01

Clinical-vignette multiple choice question (MCQ) examinations are used widely in medical education. Standardised MCQ examinations are used by licensure and certification bodies to award credentials that are meant to assure stakeholders as to the quality of physicians. Such uses are based on the interpretation of MCQ examination performance as giving meaningful information about the quality of clinical reasoning. There are several assumptions foundational to these interpretations and uses of standardised MCQ examinations. This study explores the implicit assumption that cognitive processes elicited by clinical-vignette MCQ items are like the processes thought to occur with 'real-world' clinical reasoning as theorised by dual-process theory. Fourteen participants (three medical students, five residents and six staff physicians) completed three sets of five timed MCQ items (total 15) from the Medical Knowledge Self-Assessment Program (MKSAP). Upon answering a set of MCQs, each participant completed a retrospective think aloud (TA) protocol. Using constant comparative analysis (CCA) methods sensitised by dual-process theory, we performed a qualitative thematic analysis. Examinee behaviours fell into three categories: clinical reasoning behaviours, test-taking behaviours and reactions to the MCQ. Consistent with dual-process theory, statements about clinical reasoning behaviours were divided into two sub-categories: analytical reasoning and non-analytical reasoning. Each of these categories included several themes. Our study provides some validity evidence that test-takers' descriptions of their cognitive processes during completion of high-quality clinical-vignette MCQs align with processes expected in real-world clinical reasoning. This supports one of the assumptions important for interpretations of MCQ examination scores as meaningful measures of clinical reasoning. Our observations also suggest that MCQs elicit other cognitive processes, including certain test-taking behaviours, that seem 'inauthentic' to real-world clinical reasoning. Further research is needed to explore if similar themes arise in other contexts (e.g. simulated patient encounters) and how observed behaviours relate to performance on MCQ-based assessments. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to recognize and respond to clinical deterioration.

PubMed

Liaw, Sok Ying; Rashasegaran, Ahtherai; Wong, Lai Fun; Deneen, Christopher Charles; Cooper, Simon; Levett-Jones, Tracy; Goh, Hongli Sam; Ignacio, Jeanette

2018-03-01

The development of clinical reasoning skills in recognising and responding to clinical deterioration is essential in pre-registration nursing education. Simulation has been increasingly used by educators to develop this skill. To develop and evaluate the psychometric properties of a Clinical Reasoning Evaluation Simulation Tool (CREST) for measuring clinical reasoning skills in recognising and responding to clinical deterioration in a simulated environment. A scale development with psychometric testing and mixed methods study. Nursing students and academic staff were recruited at a university. A three-phase prospective study was conducted. Phase 1 involved the development and content validation of the CREST; Phase 2 included the psychometric testing of the tool with 15 second-year and 15 third-year nursing students who undertook the simulation-based assessment; Phase 3 involved the usability testing of the tool with nine academic staff through a survey questionnaire and focus group discussion. A 10-item CREST was developed based on a model of clinical reasoning. A content validity of 0.93 was obtained from the validation of 15 international experts. The construct validity was supported as the third-year students demonstrated significantly higher (p<0.001) clinical reasoning scores than the second-year students. The concurrent validity was also supported with significant positive correlations between global rating scores and almost all subscale scores, and the total scores. The predictive validity was supported with an existing tool. The internal consistency was high with a Cronbach's alpha of 0.92. A high inter-rater reliability was demonstrated with an intraclass correlation coefficient of 0.88. The usability of the tool was rated positively by the nurse educators but the need to ease the scoring process was highlighted. A valid and reliable tool was developed to measure the effectiveness of simulation in developing clinical reasoning skills for recognising and responding to clinical deterioration. Copyright © 2017. Published by Elsevier Ltd.

Visualizing complex processes using a cognitive-mapping tool to support the learning of clinical reasoning.

PubMed

Wu, Bian; Wang, Minhong; Grotzer, Tina A; Liu, Jun; Johnson, Janice M

2016-08-22

Practical experience with clinical cases has played an important role in supporting the learning of clinical reasoning. However, learning through practical experience involves complex processes difficult to be captured by students. This study aimed to examine the effects of a computer-based cognitive-mapping approach that helps students to externalize the reasoning process and the knowledge underlying the reasoning process when they work with clinical cases. A comparison between the cognitive-mapping approach and the verbal-text approach was made by analyzing their effects on learning outcomes. Fifty-two third-year or higher students from two medical schools participated in the study. Students in the experimental group used the computer-base cognitive-mapping approach, while the control group used the verbal-text approach, to make sense of their thinking and actions when they worked with four simulated cases over 4 weeks. For each case, students in both groups reported their reasoning process (involving data capture, hypotheses formulation, and reasoning with justifications) and the underlying knowledge (involving identified concepts and the relationships between the concepts) using the given approach. The learning products (cognitive maps or verbal text) revealed that students in the cognitive-mapping group outperformed those in the verbal-text group in the reasoning process, but not in making sense of the knowledge underlying the reasoning process. No significant differences were found in a knowledge posttest between the two groups. The computer-based cognitive-mapping approach has shown a promising advantage over the verbal-text approach in improving students' reasoning performance. Further studies are needed to examine the effects of the cognitive-mapping approach in improving the construction of subject-matter knowledge on the basis of practical experience.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2011-06-01

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery. © 2011 Blackwell Publishing Asia Pty Ltd.

Promoting the Self-Regulation of Clinical Reasoning Skills in Nursing Students

PubMed Central

Kuiper, R; Pesut, D; Kautz, D

2009-01-01

Aim: The purpose of this paper is to describe the research surrounding the theories and models the authors united to describe the essential components of clinical reasoning in nursing practice education. The research was conducted with nursing students in health care settings through the application of teaching and learning strategies with the Self-Regulated Learning Model (SRL) and the Outcome-Present-State-Test (OPT) Model of Reflective Clinical Reasoning. Standardized nursing languages provided the content and clinical vocabulary for the clinical reasoning task. Materials and Methods: This descriptive study described the application of the OPT model of clinical reasoning, use of nursing language content, and reflective journals based on the SRL model with 66 undergraduate nursing students over an 8 month period of time. The study tested the idea that self-regulation of clinical reasoning skills can be developed using self-regulation theory and the OPT model. Results: This research supports a framework for effective teaching and learning methods to promote and document learner progress in mastering clinical reasoning skills. Self-regulated Learning strategies coupled with the OPT model suggest benefits of self-observation and self-monitoring during clinical reasoning activities, and pinpoints where guidance is needed for the development of cognitive and metacognitive awareness. Recommendations and Conclusions: Thinking and reasoning about the complexities of patient care needs requires attention to the content, processes and outcomes that make a nursing care difference. These principles and concepts are valuable to clinical decision making for nurses globally as they deal with local, regional, national and international health care issues. PMID:19888432

Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis.

PubMed

Peters, Amanda; Vanstone, Meredith; Monteiro, Sandra; Norman, Geoff; Sherbino, Jonathan; Sibbald, Matthew

2017-05-01

According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians' use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians' stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.

Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol

PubMed Central

Moussa, Ahmed; Loye, Nathalie; Charlin, Bernard; Audétat, Marie-Claude

2016-01-01

Background Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback. Objective The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents. Methods This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares. Results This study is in its preliminary stages and the results are expected to be made available by April, 2016. Conclusions This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students. PMID:26888076

Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol.

PubMed

Pennaforte, Thomas; Moussa, Ahmed; Loye, Nathalie; Charlin, Bernard; Audétat, Marie-Claude

2016-02-17

Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback. The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents. This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares. This study is in its preliminary stages and the results are expected to be made available by April, 2016. This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students.

An Algorithm Using Twelve Properties of Antibiotics to Find the Recommended Antibiotics, as in CPGs.

PubMed

Tsopra, R; Venot, A; Duclos, C

2014-01-01

Clinical Decision Support Systems (CDSS) incorporating justifications, updating and adjustable recommendations can considerably improve the quality of healthcare. We propose a new approach to the design of CDSS for empiric antibiotic prescription, based on implementation of the deeper medical reasoning used by experts in the development of clinical practice guidelines (CPGs), to deduce the recommended antibiotics. We investigated two methods ("exclusion" versus "scoring") for reproducing this reasoning based on antibiotic properties. The "exclusion" method reproduced expert reasoning the more accurately, retrieving the full list of recommended antibiotics for almost all clinical situations. This approach has several advantages: (i) it provides convincing explanations for physicians; (ii) updating could easily be incorporated into the CDSS; (iii) it can provide recommendations for clinical situations missing from CPGs.

Clinical judgement in the era of big data and predictive analytics.

PubMed

Chin-Yee, Benjamin; Upshur, Ross

2018-06-01

Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data-driven, mathematical approaches which we contrast with narrative, virtue-based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue-based clinical reasoning will remain indispensable in an era of big data and predictive analytics. © 2017 John Wiley & Sons, Ltd.

Clinical reasoning in nursing, a think-aloud study using virtual patients - a base for an innovative assessment.

PubMed

Forsberg, Elenita; Ziegert, Kristina; Hult, Håkan; Fors, Uno

2014-04-01

In health-care education, it is important to assess the competencies that are essential for the professional role. To develop clinical reasoning skills is crucial for nursing practice and therefore an important learning outcome in nursing education programmes. Virtual patients (VPs) are interactive computer simulations of real-life clinical scenarios and have been suggested for use not only for learning, but also for assessment of clinical reasoning. The aim of this study was to investigate how experienced paediatric nurses reason regarding complex VP cases and how they make clinical decisions. The study was also aimed to give information about possible issues that should be assessed in clinical reasoning exams for post-graduate students in diploma specialist paediatric nursing education. The information from this study is believed to be of high value when developing scoring and grading models for a VP-based examination for the specialist diploma in paediatric nursing education. Using the think-aloud method, data were collected from 30 RNs working in Swedish paediatric departments, and child or school health-care centres. Content analysis was used to analyse the data. The results indicate that experienced nurses try to consolidate their hypotheses by seeing a pattern and judging the value of signs, symptoms, physical examinations, laboratory tests and radiology. They show high specific competence but earlier experience of similar cases was also of importance for the decision making. The nurses thought it was an innovative assessment focusing on clinical reasoning and clinical decision making. They thought it was an enjoyable way to be assessed and that all three main issues could be assessed using VPs. In conclusion, VPs seem to be a possible model for assessing the clinical reasoning process and clinical decision making, but how to score and grade such exams needs further research. © 2013.

Enhancing the Clinical Reasoning Skills of Postgraduate Students in Internal Medicine Through Medical Nonfiction and Nonmedical Fiction Extracurricular Books.

PubMed

Kiran, H S; Chacko, Thomas V; Murthy, K A Sudharshana; Gowdappa, H Basavana

2016-12-01

To improve the clinical reasoning skills of postgraduate students in internal medicine through 2 kinds of extracurricular books: medical nonfiction and nonmedical fiction. Clinical reasoning is difficult to define, understand, observe, teach, and measure. This is an educational innovation under an experimental framework based on a cognitive intervention grounded in constructivist and cognitivist theories. This study was conducted from June 1, 2014, through May 31, 2015. It was a pre-post, randomized, controlled, prospective, mixed-methods, small-group study. The intervention was through medical nonfiction and nonmedical fiction books. The process was structured to ensure that the students would read the material in phases and reflect on them. Clinical reasoning (pretests and posttests) was quantitatively assessed using the Diagnostic Thinking Inventory (DTI) and clinical reasoning exercises (CREs) and their assessment using a rubric. A qualitative design was used, and face-to-face semistructured interviews were conducted. Posttest total scores (DTI=188.92; CREs=53.92) were higher for the study group after the intervention compared with its own pretest scores (DTI=165.25; CREs=41.17) and with the pretest (DTI=159.27; CRE=40.73) and posttest (DTI=166.91; CREs=41.18) scores of the control group. Interviews with the study group confirmed that the intervention was acceptable and useful in daily practice. We introduced, evaluated, and proved an approach to teaching-learning clinical reasoning based on the assumption that the clinical reasoning skills of postgraduate students in internal medicine can be enhanced through 2 kinds of extracurricular books and that fun as well as interest will enhance learning. This study is not only about teaching-learning clinical reasoning but also about the humanities in medical education. Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Bardoxolone Brings Nrf2-Based Therapies to Light

PubMed Central

2013-01-01

Abstract The targeted activation of nuclear factor erythroid-derived-2-like 2 (Nrf2) to alleviate symptoms of chronic kidney disease has recently garnered much attention. Unfortunately, the greatest clinical success to date, bardoxolone, failed in phase III clinical trial for unspecified safety reasons. The present letter to the editor discusses the clinical development of bardoxolone and explores potential reasons for the ultimate withdrawal from clinical trials. In particular, was the correct clinical indication pursued and would improved specificity have mitigated the safety concerns? Ultimately, it is concluded that the right clinical indication and heightened specificity will lead to successful Nrf2-based therapies. Therefore, the bardoxolone clinical results do not dampen enthusiasm for Nrf2-based therapies; rather it illuminates the clinical potential of the Nrf2 pathway as a drug target. Antioxid. Redox Signal. 19, 517–518. PMID:23227819

Clinical reasoning in neurology: use of the repertory grid technique to investigate the reasoning of an experienced occupational therapist.

PubMed

Kuipers, Kathy; Grice, James W

2009-08-01

The aim of this paper is to describe the use of a structured interview methodology, the repertory grid technique, for investigating the clinical reasoning of an experienced occupational therapist in the domain of upper limb hypertonia as a result of brain injury. Repertory grid interviews were completed before and after exposure to a protocol designed to guide clinical reasoning and decision-making in relation to upper limb neurological rehabilitation. Data were subjected to both qualitative and quantitative analyses. Qualitative analysis focussed on clinical reasoning content. Common themes across the pre- and post-exposure interviews were the use of theoretical frameworks and practice models, the significance of clinical expertise, and discrimination of 'broad' and 'specific' aspects, as well as differentiation between 'therapist and client-related' aspects of the clinical situation. Quantitative analysis indicated that for both pre- and post-exposure repertory grids, clinical reasoning was structured in terms of two main concepts. In the pre-exposure grid, these were related to the therapist's role, and to the 'scope' of practice tasks (either broad or specific). In the post-exposure grid the two main concepts were upper limb performance, and client-centred aspects of the therapy process. The repertory grid technique is proposed as an effective tool for exploring occupational therapy clinical reasoning, based on its capacity for accessing personal frames of reference, and elucidating both the meaning and the structure supporting clinical reasoning.

Teaching clinical reasoning: case-based and coached.

PubMed

Kassirer, Jerome P

2010-07-01

Optimal medical care is critically dependent on clinicians' skills to make the right diagnosis and to recommend the most appropriate therapy, and acquiring such reasoning skills is a key requirement at every level of medical education. Teaching clinical reasoning is grounded in several fundamental principles of educational theory. Adult learning theory posits that learning is best accomplished by repeated, deliberate exposure to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning, and that the participation of a coach augments the value of an educational experience. The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice. These concepts foster the teaching and learning of the diagnostic process, the complex trade-offs between the benefits and risks of diagnostic tests and treatments, and cognitive errors in clinical reasoning. The teaching of clinical reasoning need not and should not be delayed until students gain a full understanding of anatomy and pathophysiology. Concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification provide both the language and the methods of clinical problem solving. Expertise is attainable even though the precise mechanisms of achieving it are not known.

Faculty Development for Fostering Clinical Reasoning Skills in Early Medical Students Using a Modified Bayesian Approach.

PubMed

Addy, Tracie Marcella; Hafler, Janet; Galerneau, France

2016-01-01

Clinical reasoning is a necessary skill for medical students to acquire in the course of their education, and there is evidence that they can start this process at the undergraduate level. However, physician educators who are experts in their given fields may have difficulty conveying their complex thought processes to students. Providing faculty development that equips educators with tools to teach clinical reasoning may support skill development in early medical students. We provided faculty development on a modified Bayesian method of teaching clinical reasoning to clinician educators who facilitated small-group, case-based workshops with 2nd-year medical students. We interviewed them before and after the module regarding their perceptions on teaching clinical reasoning. We solicited feedback from the students about the effectiveness of the method in developing their clinical reasoning skills. We carried out this project during an institutional curriculum rebuild where clinical reasoning was a defined goal. At the time of the intervention, there was also increased involvement of the Teaching and Learning Center in elevating the status of teaching and learning. There was high overall satisfaction with the faculty development program. Both the faculty and the students described the modified Bayesian approach as effective in fostering the development of clinical reasoning skills. Through this work, we learned how to form a beneficial partnership between a clinician educator and Teaching and Learning Center to promote faculty development on a clinical reasoning teaching method for early medical students. We uncovered challenges faced by both faculty and early learners in this study. We observed that our faculty chose to utilize the method of teaching clinical reasoning in a variety of manners in the classroom. Despite obstacles and differing approaches utilized, we believe that this model can be emulated at other institutions to foster the development of clinical reasoning skills in preclerkship students.

How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia.

PubMed

Findyartini, Ardi; Hawthorne, Lesleyanne; McColl, Geoff; Chiavaroli, Neville

2016-07-21

The majority of schools in the Asia-Pacific region have adopted medical curricula based on western pedagogy. However to date there has been minimal exploration of the influence of the culture of learning on the teaching and learning process. This paper explores this issue in relation to clinical reasoning. A comparative case study was conducted in 2 medical schools in Australia (University of Melbourne) and Asia (Universitas Indonesia). It involved assessment of medical students' attitudes to clinical reasoning through administration of the Diagnostic Thinking Inventory (DTI), followed by qualitative interviews which explored related cultural issues. A total of 11 student focus group discussions (45 students) and 24 individual medical teacher interviews were conducted, followed by thematic analysis. Students from Universitas Indonesia were found to score lower on the Flexibility in Thinking subscale of the DTI. Qualitative data analysis based on Hofstede's theoretical constructs concerning the culture of learning also highlighted clear differences in relation to attitudes to authority and uncertainty avoidance, with potential impacts on attitudes to teaching and learning of clinical reasoning in undergraduate medical education. Different attitudes to teaching and learning clinical reasoning reflecting western and Asian cultures of learning were identified in this study. The potential impact of cultural differences should be understood when planning how clinical reasoning can be best taught and learned in the changing global contexts of medical education, especially when the western medical education approach is implemented in Asian contexts.

Influences of Sociocultural Factors Within the Clinical Learning Environment on Students' Perceptions of Learning: An Integrative Review.

PubMed

Jessee, Mary Ann

A persistent deficit in new graduate nurses' clinical reasoning skill exists. Clinical reasoning is best learned in the sociocultural clinical learning environment (CLE), yet many CLEs fail to engage nursing students in the cognitive work of nursing that promotes development of clinical reasoning. Despite two decades of recommendations to improve CLEs based on students' perceptions of learning, widespread improvement remains elusive. The aim of this review was to synthesize what is known about the influence of sociocultural factors in the acute-care CLE on prelicensure nursing students' perceptions of learning, for the purpose of identifying factors that when modified may promote improvement of clinical reasoning skill. The integrative review methodology was used to synthesize and identify gaps in evidence on students' perceptions of learning in the acute-care CLE. Global commonalities exist in the impact of the sociocultural CLE on students' perceptions of learning, including overall sociocultural atmosphere, membership in the health care team, supervisory relationships, peer relationships, and clinical education structure. This review provides evidence that modification of CLE factors and examination of their influence on measurable learning outcomes such as clinical reasoning are the necessary next steps to facilitate improvement of new graduate nurses' clinical reasoning skill. Copyright © 2016 Elsevier Inc. All rights reserved.

Virtual patients design and its effect on clinical reasoning and student experience: a protocol for a randomised factorial multi-centre study.

PubMed

Bateman, James; Allen, Maggie E; Kidd, Jane; Parsons, Nick; Davies, David

2012-08-01

Virtual Patients (VPs) are web-based representations of realistic clinical cases. They are proposed as being an optimal method for teaching clinical reasoning skills. International standards exist which define precisely what constitutes a VP. There are multiple design possibilities for VPs, however there is little formal evidence to support individual design features. The purpose of this trial is to explore the effect of two different potentially important design features on clinical reasoning skills and the student experience. These are the branching case pathways (present or absent) and structured clinical reasoning feedback (present or absent). This is a multi-centre randomised 2 x 2 factorial design study evaluating two independent variables of VP design, branching (present or absent), and structured clinical reasoning feedback (present or absent).The study will be carried out in medical student volunteers in one year group from three university medical schools in the United Kingdom, Warwick, Keele and Birmingham. There are four core musculoskeletal topics. Each case can be designed in four different ways, equating to 16 VPs required for the research. Students will be randomised to four groups, completing the four VP topics in the same order, but with each group exposed to a different VP design sequentially. All students will be exposed to the four designs. Primary outcomes are performance for each case design in a standardized fifteen item clinical reasoning assessment, integrated into each VP, which is identical for each topic. Additionally a 15-item self-reported evaluation is completed for each VP, based on a widely used EViP tool. Student patterns of use of the VPs will be recorded.In one centre, formative clinical and examination performance will be recorded, along with a self reported pre and post-intervention reasoning score, the DTI. Our power calculations indicate a sample size of 112 is required for both primary outcomes. This trial will provide robust evidence to support the effectiveness of different designs of virtual patients, based on student performance and evaluation. The cases and all learning materials will be open access and available on a Creative Commons Attribution-Share-Alike license.

A Computational Model of Reasoning from the Clinical Literature

PubMed Central

Rennels, Glenn D.

1986-01-01

This paper explores the premise that a formalized representation of empirical studies can play a central role in computer-based decision support. The specific motivations underlying this research include the following propositions: 1. Reasoning from experimental evidence contained in the clinical literature is central to the decisions physicians make in patient care. 2. A computational model, based upon a declarative representation for published reports of clinical studies, can drive a computer program that selectively tailors knowledge of the clinical literature as it is applied to a particular case. 3. The development of such a computational model is an important first step toward filling a void in computer-based decision support systems. Furthermore, the model may help us better understand the general principles of reasoning from experimental evidence both in medicine and other domains. Roundsman is a developmental computer system which draws upon structured representations of the clinical literature in order to critique plans for the management of primary breast cancer. Roundsman is able to produce patient-specific analyses of breast cancer management options based on the 24 clinical studies currently encoded in its knowledge base. The Roundsman system is a first step in exploring how the computer can help to bring a critical analysis of the relevant literature to the physician, structured around a particular patient and treatment decision.

Clinical reasoning of junior doctors in emergency medicine: a grounded theory study.

PubMed

Adams, E; Goyder, C; Heneghan, C; Brand, L; Ajjawi, R

2017-02-01

Emergency medicine (EM) has a high case turnover and acuity making it a demanding clinical reasoning domain especially for junior doctors who lack experience. We aimed to better understand their clinical reasoning using dual cognition as a guiding theory. EM junior doctors were recruited from six hospitals in the south of England to participate in semi-structured interviews (n=20) and focus groups (n=17) based on recall of two recent cases. Transcripts were analysed using a grounded theory approach to identify themes and to develop a model of junior doctors' clinical reasoning in EM. Within cases, clinical reasoning occurred in three phases. In phase 1 (case framing), initial case cues and first impressions were predominantly intuitive, but checked by analytical thought and determined the urgency of clinical assessment. In phase 2 (evolving reasoning), non-analytical single cue and pattern recognitions were common which were subsequently validated by specific analytical strategies such as use of red flags. In phase 3 (ongoing uncertainty) analytical self-monitoring and reassurance strategies were used to precipitate a decision regarding discharge. We found a constant dialectic between intuitive and analytical cognition throughout the reasoning process. Our model of clinical reasoning by EM junior doctors illustrates the specific contextual manifestations of the dual cognition theory. Distinct diagnostic strategies are identified and together these give EM learners and educators a framework and vocabulary for discussion and learning about clinical reasoning. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

An Algorithm Using Twelve Properties of Antibiotics to Find the Recommended Antibiotics, as in CPGs

PubMed Central

Tsopra, R.; Venot, A.; Duclos, C.

2014-01-01

Background Clinical Decision Support Systems (CDSS) incorporating justifications, updating and adjustable recommendations can considerably improve the quality of healthcare. We propose a new approach to the design of CDSS for empiric antibiotic prescription, based on implementation of the deeper medical reasoning used by experts in the development of clinical practice guidelines (CPGs), to deduce the recommended antibiotics. Methods We investigated two methods (“exclusion” versus “scoring”) for reproducing this reasoning based on antibiotic properties. Results The “exclusion” method reproduced expert reasoning the more accurately, retrieving the full list of recommended antibiotics for almost all clinical situations. Discussion This approach has several advantages: (i) it provides convincing explanations for physicians; (ii) updating could easily be incorporated into the CDSS; (iii) it can provide recommendations for clinical situations missing from CPGs. PMID:25954422

Nurses' clinical reasoning practices that support safe medication administration: An integrative review of the literature.

PubMed

Rohde, Emily; Domm, Elizabeth

2018-02-01

To review the current literature about nurses' clinical reasoning practices that support safe medication administration. The literature about medication administration frequently focuses on avoiding medication errors. Nurses' clinical reasoning used during medication administration to maintain medication safety receives less attention in the literature. As healthcare professionals, nurses work closely with patients, assessing and intervening to promote mediation safety prior to, during and after medication administration. They also provide discharge teaching about using medication safely. Nurses' clinical reasoning and practices that support medication safety are often invisible when the focus is medication errors avoidance. An integrative literature review was guided by Whittemore and Knafl's (Journal of Advanced Nursing, 5, 2005 and 546) five-stage review of the 11 articles that met review criteria. This review is modelled after Gaffney et al.'s (Journal of Clinical Nursing, 25, 2016 and 906) integrative review on medical error recovery. Health databases were accessed and systematically searched for research reporting nurses' clinical reasoning practices that supported safe medication administration. The level and quality of evidence of the included research articles were assessed using The Johns Hopkins Nursing Evidence-Based Practice Rating Scale©. Nurses have a central role in safe medication administration, including but not limited to risk awareness about the potential for medication errors. Nurses assess patients and their medication and use knowledge and clinical reasoning to administer medication safely. Results indicated nurses' use of clinical reasoning to maintain safe medication administration was inadequately articulated in 10 of 11 studies reviewed. Nurses are primarily responsible for safe medication administration. Nurses draw from their foundational knowledge of patient conditions and organisational processes and use clinical reasoning that supports safe medication practice. There was minimal evidence clearly articulating nurses' clinical reasoning used to support medication safety. This review focused on finding evidence of nurses' clinical reasoning that supported safe medication administration. © 2017 John Wiley & Sons Ltd.

The Role of Argumentation in Hypothetico-Deductive Reasoning during Problem-Based Learning in Medical Education: A Conceptual Framework

ERIC Educational Resources Information Center

Ju, Hyunjung; Choi, Ikseon

2018-01-01

One of the important goals of problem-based learning (PBL) in medical education is to enhance medical students' clinical reasoning--hypothetico-deductive reasoning (HDR) in particular--through small group discussions. However, few studies have focused on explicit strategies for promoting students' HDR during group discussions in PBL. This paper…

A clinical reasoning model focused on clients' behaviour change with reference to physiotherapists: its multiphase development and validation.

PubMed

Elvén, Maria; Hochwälder, Jacek; Dean, Elizabeth; Söderlund, Anne

2015-05-01

A biopsychosocial approach and behaviour change strategies have long been proposed to serve as a basis for addressing current multifaceted health problems. This emphasis has implications for clinical reasoning of health professionals. This study's aim was to develop and validate a conceptual model to guide physiotherapists' clinical reasoning focused on clients' behaviour change. Phase 1 consisted of the exploration of existing research and the research team's experiences and knowledge. Phases 2a and 2b consisted of validation and refinement of the model based on input from physiotherapy students in two focus groups (n = 5 per group) and from experts in behavioural medicine (n = 9). Phase 1 generated theoretical and evidence bases for the first version of a model. Phases 2a and 2b established the validity and value of the model. The final model described clinical reasoning focused on clients' behaviour change as a cognitive, reflective, collaborative and iterative process with multiple interrelated levels that included input from the client and physiotherapist, a functional behavioural analysis of the activity-related target behaviour and the selection of strategies for behaviour change. This unique model, theory- and evidence-informed, has been developed to help physiotherapists to apply clinical reasoning systematically in the process of behaviour change with their clients.

What's in a Label? Is Diagnosis the Start or the End of Clinical Reasoning?

PubMed

Ilgen, Jonathan S; Eva, Kevin W; Regehr, Glenn

2016-04-01

Diagnostic reasoning has received substantial attention in the literature, yet what we mean by "diagnosis" may vary. Diagnosis can align with assignment of a "label," where a constellation of signs, symptoms, and test results is unified into a solution at a single point in time. This "diagnostic labeling" conceptualization is embodied in our case-based learning curricula, published case reports, and research studies, all of which treat diagnostic accuracy as the primary outcome. However, this conceptualization may oversimplify the richly iterative and evolutionary nature of clinical reasoning in many settings. Diagnosis can also represent a process of guiding one's thoughts by "making meaning" from data that are intrinsically dynamic, experienced idiosyncratically, negotiated among team members, and rich with opportunities for exploration. Thus, there are two complementary constructions of diagnosis: 1) the correct solution resulting from a diagnostic reasoning process, and 2) a dynamic aid to an ongoing clinical reasoning process. This article discusses the importance of recognizing these two conceptualizations of "diagnosis," outlines the unintended consequences of emphasizing diagnostic labeling as the primary goal of clinical reasoning, and suggests how framing diagnosis as an ongoing process of meaning-making might change how we think about teaching and assessing clinical reasoning.

Emerging medical informatics with case-based reasoning for aiding clinical decision in multi-agent system.

PubMed

Shen, Ying; Colloc, Joël; Jacquet-Andrieu, Armelle; Lei, Kai

2015-08-01

This research aims to depict the methodological steps and tools about the combined operation of case-based reasoning (CBR) and multi-agent system (MAS) to expose the ontological application in the field of clinical decision support. The multi-agent architecture works for the consideration of the whole cycle of clinical decision-making adaptable to many medical aspects such as the diagnosis, prognosis, treatment, therapeutic monitoring of gastric cancer. In the multi-agent architecture, the ontological agent type employs the domain knowledge to ease the extraction of similar clinical cases and provide treatment suggestions to patients and physicians. Ontological agent is used for the extension of domain hierarchy and the interpretation of input requests. Case-based reasoning memorizes and restores experience data for solving similar problems, with the help of matching approach and defined interfaces of ontologies. A typical case is developed to illustrate the implementation of the knowledge acquisition and restitution of medical experts. Copyright © 2015 Elsevier Inc. All rights reserved.

A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study.

PubMed

Hege, Inga; Kononowicz, Andrzej A; Adler, Martin

2017-11-02

Clinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning. Keeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills. We designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient's illness script as a concept map when they are working on a VP scenario. The student's map is compared with the experts' reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license. We conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons. The presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms. ©Inga Hege, Andrzej A Kononowicz, Martin Adler. Originally published in JMIR Medical Education (http://mededu.jmir.org), 02.11.2017.

Argumentation and evidence.

PubMed

Upshur, R E G; Colak, Errol

2003-01-01

This essay explores the role of informal logic and its application in the context of current debates regarding evidence-based medicine. This aim is achieved through a discussion of the goals and objectives of evidence-based medicine and a review of the criticisms raised against evidence-based medicine. The contributions to informal logic by Stephen Toulmin and Douglas Walton are explicated and their relevance for evidence-based medicine is discussed in relation to a common clinical scenario: hypertension management. This essay concludes with a discussion on the relationship between clinical reasoning, rationality, and evidence. It is argued that informal logic has the virtue of bringing explicitness to the role of evidence in clinical reasoning, and brings sensitivity to understanding the role of dialogical context in the need for evidence in clinical decision making.

Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students' case presentation and differential diagnostic skills.

PubMed

Harendza, Sigrid; Krenz, Ingo; Klinge, Andreas; Wendt, Ulrike; Janneck, Matthias

2017-01-01

Background: Clinical reasoning, comprising the processes of clinical thinking, which form the basis of medical decisions, constitutes a central competence in the clinical routine on which diagnostic and therapeutic steps are based. In medical curricula in Germany, clinical reasoning is currently taught explicitly only to a small extend. Therefore, the aim of this project was to develop and implement a clinical reasoning course in the final year of undergraduate medical training. Project description: A clinical reasoning course with six learning units and 18 learning objectives was developed, which was taught by two to four instructors on the basis of 32 paper cases from the clinical practice of the instructors. In the years 2011 to 2013, the course of eight weeks with two hours per week was taught seven times. Before the first and after the last seminar, the participating students filled out a self-assessment questionnaire with a 6-point Likert scale regarding eight different clinical reasoning skills. At the same times, they received a patient case with the assignment to prepare a case presentation and differential diagnoses. Results: From 128 participating students altogether, 42 complete data sets were available. After the course, participants assessed themselves significantly better than before the course in all eight clinical reasoning skills, for example in "Summarizing and presentation of a paper case" or in the "Skill to enumerate differential diagnoses" (p<0.05). The greatest increase occurred in the skill to recognize typical cognitive errors in medicine and to identify risk situations for their occurrence (pre: 2.98±0.92 and retro-pre: 2.64±1.01, respectively, versus post: 4.38±0.88). Based on the ratio of number of words used per keywords used the problem presentation of the paper case was significantly more focused after the course (p=0.011). A significant increase in the number of gathered differential diagnoses was not detected after the course. Conclusion: The newly developed and established Clinical Reasoning Course leads to a gain in the desired skills from the students' self-assessment perspective and to a more structured case presentation. To establish better options to exercise clinical reasoning, a longitudinal implementation in the medical curriculum seems to be desirable. Faculty training would be useful to implement the concept as standardized as possible.

Implementation of a Clinical Reasoning Course in the Internal Medicine trimester of the final year of undergraduate medical training and its effect on students' case presentation and differential diagnostic skills

PubMed Central

Harendza, Sigrid; Krenz, Ingo; Klinge, Andreas; Wendt, Ulrike; Janneck, Matthias

2017-01-01

Background: Clinical reasoning, comprising the processes of clinical thinking, which form the basis of medical decisions, constitutes a central competence in the clinical routine on which diagnostic and therapeutic steps are based. In medical curricula in Germany, clinical reasoning is currently taught explicitly only to a small extend. Therefore, the aim of this project was to develop and implement a clinical reasoning course in the final year of undergraduate medical training. Project description: A clinical reasoning course with six learning units and 18 learning objectives was developed, which was taught by two to four instructors on the basis of 32 paper cases from the clinical practice of the instructors. In the years 2011 to 2013, the course of eight weeks with two hours per week was taught seven times. Before the first and after the last seminar, the participating students filled out a self-assessment questionnaire with a 6-point Likert scale regarding eight different clinical reasoning skills. At the same times, they received a patient case with the assignment to prepare a case presentation and differential diagnoses. Results: From 128 participating students altogether, 42 complete data sets were available. After the course, participants assessed themselves significantly better than before the course in all eight clinical reasoning skills, for example in “Summarizing and presentation of a paper case” or in the “Skill to enumerate differential diagnoses” (p<0.05). The greatest increase occurred in the skill to recognize typical cognitive errors in medicine and to identify risk situations for their occurrence (pre: 2.98±0.92 and retro-pre: 2.64±1.01, respectively, versus post: 4.38±0.88). Based on the ratio of number of words used per keywords used the problem presentation of the paper case was significantly more focused after the course (p=0.011). A significant increase in the number of gathered differential diagnoses was not detected after the course. Conclusion: The newly developed and established Clinical Reasoning Course leads to a gain in the desired skills from the students’ self-assessment perspective and to a more structured case presentation. To establish better options to exercise clinical reasoning, a longitudinal implementation in the medical curriculum seems to be desirable. Faculty training would be useful to implement the concept as standardized as possible. PMID:29226234

A functional neuroimaging study of the clinical reasoning of medical students.

PubMed

Chang, Hyung-Joo; Kang, June; Ham, Byung-Joo; Lee, Young-Mee

2016-12-01

As clinical reasoning is a fundamental competence of physicians for good clinical practices, medical academics have endeavored to teach reasoning skills to undergraduate students. However, our current understanding of student-level clinical reasoning is limited, mainly because of the lack of evaluation tools for this internal cognitive process. This functional magnetic resonance imaging (fMRI) study aimed to examine the clinical reasoning processes of medical students in response to problem-solving questions. We recruited 24 2nd-year medical students who had completed their preclinical curriculum. They answered 40 clinical vignette-based multiple-choice questions during fMRI scanning. We compared the imaging data for 20 problem-solving questions (reasoning task) and 20 recall questions (recall task). Compared to the recall task, the reasoning task resulted in significantly greater activation in nine brain regions, including the dorsolateral prefrontal cortex and inferior parietal cortex, which are known to be associated with executive function and deductive reasoning. During the recall task, significant activation was observed in the brain regions that are related to memory and emotions, including the amygdala and ventromedial prefrontal cortex. Our results support that medical students mainly solve clinical questions with deductive reasoning involving prior knowledge structures and executive functions. The problem-solving questions induced the students to utilize higher cognitive functions compared with the recall questions. Interestingly, the results suggested that the students experienced some emotional distress while they were solving the recall questions. In addition, these results suggest that fMRI is a promising research tool for investigating students' cognitive processes.

The design and implementation of an Interactive Computerised Decision Support Framework (ICDSF) as a strategy to improve nursing students' clinical reasoning skills.

PubMed

Hoffman, Kerry; Dempsey, Jennifer; Levett-Jones, Tracy; Noble, Danielle; Hickey, Noelene; Jeong, Sarah; Hunter, Sharyn; Norton, Carol

2011-08-01

This paper describes the conceptual design and testing of an Interactive Computerised Decision Support Framework (ICDSF) which was constructed to enable student nurses to "think like a nurse." The ICDSF was based on a model of clinical reasoning. Teaching student nurses to reason clinically is important as poor clinical reasoning skills can lead to "failure-to rescue" of deteriorating patients. The framework of the ICDSF was based on nursing concepts to encourage deep learning and transferability of knowledge. The principles of active student participation, situated cognition to solve problems, authenticity, and cognitive rehearsal were used to develop the ICDSF. The ICDSF was designed in such a way that students moved through it in a step-wise fashion and were required to achieve competency at each step before proceeding to the next. The quality of the ICDSF was evaluated using a questionairre survey, students' written comments and student assessment measures on a pilot and the ICDSF. Overall students were highly satisfied with the clinical scenarios of the ICDSF and believed they were an interesting and useful way to engage in authentic clinical learning. They also believed the ICDSF was useful in developing cognitive skills such as clinical reasoning, problem-solving and decision-making. Some reported issues were the need for good technical support and the lack of face to face contact when using e-learning. Some students also believed the ICDSF was less useful than actual clinical placements. Copyright © 2010 Elsevier Ltd. All rights reserved.

The Impact of Humanities-Based Teaching and Learning Strategies on Critical Thinking and Clinical Reasoning Development among BSN Students

ERIC Educational Resources Information Center

Brodhead, Josette

2016-01-01

The ability to function effectively in a dynamic, culturally diverse healthcare environment requires both critical thinking and clinical reasoning skills. The American Association of Colleges of Nursing (AACN, 2008) recognizes the importance of humanities in the baccalaureate nursing curriculum. This quasi-experimental, nonrandomized…

Assessing the use of cognitive heuristic representativeness in clinical reasoning.

PubMed

Payne, Velma L; Crowley, Rebecca S; Crowley, Rebecca

2008-11-06

We performed a pilot study to investigate use of the cognitive heuristic Representativeness in clinical reasoning. We tested a set of tasks and assessments to determine whether subjects used the heuristics in reasoning, to obtain initial frequencies of heuristic use and related cognitive errors, and to collect cognitive process data using think-aloud techniques. The study investigates two aspects of the Representativeness heuristic - judging by perceived frequency and representativeness as causal beliefs. Results show that subjects apply both aspects of the heuristic during reasoning, and make errors related to misapplication of these heuristics. Subjects in this study rarely used base rates, showed significant variability in their recall of base rates, demonstrated limited ability to use provided base rates, and favored causal data in diagnosis. We conclude that the tasks and assessments we have developed provide a suitable test-bed to study the cognitive processes underlying heuristic errors.

Assessing Use of Cognitive Heuristic Representativeness in Clinical Reasoning

PubMed Central

Payne, Velma L.; Crowley, Rebecca S.

2008-01-01

We performed a pilot study to investigate use of the cognitive heuristic Representativeness in clinical reasoning. We tested a set of tasks and assessments to determine whether subjects used the heuristics in reasoning, to obtain initial frequencies of heuristic use and related cognitive errors, and to collect cognitive process data using think-aloud techniques. The study investigates two aspects of the Representativeness heuristic - judging by perceived frequency and representativeness as causal beliefs. Results show that subjects apply both aspects of the heuristic during reasoning, and make errors related to misapplication of these heuristics. Subjects in this study rarely used base rates, showed significant variability in their recall of base rates, demonstrated limited ability to use provided base rates, and favored causal data in diagnosis. We conclude that the tasks and assessments we have developed provide a suitable test-bed to study the cognitive processes underlying heuristic errors. PMID:18999140

Professional Socialization: A Grounded Theory of the Clinical Reasoning Processes That RNs and LPNs Use to Recognize Delirium.

PubMed

El Hussein, Mohamed; Hirst, Sandra; Osuji, Joseph

2017-08-01

Delirium is an acute disorder of attention and cognition. It affects half of older adults in acute care settings and is a cause of increasing mortality and costs. Registered nurses (RNs) and licensed practical nurses (LPNs) frequently fail to recognize delirium. The goals of this research were to identify the reasoning processes that RNs and LPNs use to recognize delirium, to compare their reasoning processes, and to generate a theory that explains their clinical reasoning processes. Theoretical sampling was employed to elicit data from 28 participants using grounded theory methodology. Theoretical coding culminated in the emergence of Professional Socialization as the substantive theory. Professional Socialization emerged from participants' responses and was based on two social processes, specifically reasoning to uncover and reasoning to report. Professional Socialization makes explicit the similarities and variations in the clinical reasoning processes between RNs and LPNs and highlights their main concerns when interacting with delirious patients.

Socio-demographic and academic correlates of clinical reasoning in a dental school in South Africa.

PubMed

Postma, T C; White, J G

2017-02-01

There are no empirical studies that describe factors that may influence the development of integrated clinical reasoning skills in dental education. Hence, this study examines the association between outcomes of clinical reasoning in relation with differences in instructional design and student factors. Progress test scores, including diagnostic and treatment planning scores, of fourth and fifth year dental students (2009-2011) at the University of Pretoria, South Africa served as the outcome measures in stepwise linear regression analyses. These scores were correlated with the instructional design (lecture-based teaching and learning (LBTL = 0) or case-based teaching and learning (CBTL = 1), students' grades in Oral Biology, indicators of socio-economic status (SES) and gender. CBTL showed an independent association with progress test scores. Oral Biology scores correlated with diagnostic component scores. Diagnostic component scores correlated with treatment planning scores in the fourth year of study but not in the fifth year of study. 'SES' correlated with progress test scores in year five only, while gender showed no correlation. The empirical evidence gathered in this study provides support for scaffolded inductive teaching and learning methods to develop clinical reasoning skills. Knowledge in Oral Biology and reading skills may be important attributes to develop to ensure that students are able to reason accurately in a clinical setting. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Education strategies to foster health professional students' clinical reasoning skills.

PubMed

Rochmawati, Erna; Wiechula, Rick

2010-06-01

Clinical reasoning is an important skill for health professionals that should be developed to achieve high levels of expertise. Several education strategies have been suggested for implementation by health professional educators to foster their students' clinical reasoning skills. The strategies have included the following: problem-based learning, the integrative curriculum, reflection, and concept mapping. This review assesses which is the most effective education strategy for developing the clinical reasoning skills of health professional students. Four publications, from a total of 692 identified records, were included. Overall, this review was not able to make a final conclusion to answer the question. Therefore, there is a need to conduct more studies with larger samples and to undertake research that evaluates the following aspects: more alternate education interventions, variations in the delivery of education interventions, and the cost-effectiveness of implementing education strategies.

The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies.

PubMed

Monteiro, Sandra; Norman, Geoff; Sherbino, Jonathan

2018-06-01

There is general consensus that clinical reasoning involves 2 stages: a rapid stage where 1 or more diagnostic hypotheses are advanced and a slower stage where these hypotheses are tested or confirmed. The rapid hypothesis generation stage is considered inaccessible for analysis or observation. Consequently, recent research on clinical reasoning has focused specifically on improving the accuracy of the slower, hypothesis confirmation stage. Three perspectives have developed in this line of research, and each proposes different error reduction strategies for clinical reasoning. This paper considers these 3 perspectives and examines the underlying assumptions. Additionally, this paper reviews the evidence, or lack of, behind each class of error reduction strategies. The first perspective takes an epidemiological stance, appealing to the benefits of incorporating population data and evidence-based medicine in every day clinical reasoning. The second builds on the heuristic and bias research programme, appealing to a special class of dual process reasoning models that theorizes a rapid error prone cognitive process for problem solving with a slower more logical cognitive process capable of correcting those errors. Finally, the third perspective borrows from an exemplar model of categorization that explicitly relates clinical knowledge and experience to diagnostic accuracy. © 2018 John Wiley & Sons, Ltd.

Clinical reasoning in unimodal interventions in patients with non-specific neck pain in daily physiotherapy practice, a Delphi study.

PubMed

Maissan, Francois; Pool, Jan; Stutterheim, Eric; Wittink, Harriet; Ostelo, Raymond

2018-06-02

Neck pain is the fourth major cause of disability worldwide but sufficient evidence regarding treatment is not available. This study is a first exploratory attempt to gain insight into and consensus on the clinical reasoning of experts in patients with non-specific neck pain. First, we aimed to inventory expert opinions regarding the indication for physiotherapy when, other than neck pain, no positive signs and symptoms and no positive diagnostic tests are present. Secondly, we aimed to determine which measurement instruments are being used and when they are used to support and objectify the clinical reasoning process. Finally, we wanted to establish consensus among experts regarding the use of unimodal interventions in patients with non-specific neck pain, i.e. their sequential linear clinical reasoning. A Delphi study. A Web-based Delphi study was conducted. Fifteen experts (teachers and researchers) participated. Pain alone was deemed not be an indication for physiotherapy treatment. PROMs are mainly used for evaluative purposes and physical tests for diagnostic and evaluative purposes. Eighteen different variants of sequential linear clinical reasoning were investigated within our Delphi study. Only 6 out of 18 variants of sequential linear clinical reasoning reached more than 50% consensus. Pain alone is not an indication for physiotherapy. Insight has been obtained into which measurement instruments are used and when they are used. Consensus about sequential linear lines of clinical reasoning was poor. Copyright © 2018 Elsevier Ltd. All rights reserved.

Enhancing Critical Thinking Via a Clinical Scholar Approach.

PubMed

Simpson, Vicki; McComb, Sara A; Kirkpatrick, Jane M

2017-11-01

Safety, quality improvement, and a systems perspective are vital for nurses to provide quality evidence-based care. Responding to the call to prepare nurses with these perspectives, one school of nursing used a clinical scholar approach, enhanced by systems engineering to more intentionally develop the ability to clinically reason and apply evidence-based practice. A two-group, repeated-measures control trial was used to determine the effects of systems engineering content and support on nursing students' clinical judgment and critical thinking skills. Findings indicated this approach had a positive effects on student's clinical judgment and clinical reasoning skills. This approach helped students view health care issues from a broader perspective and use evidence to guide solution development, enhancing the focus on evidence-based practice, and quality improvement. Intentional integration of an evidence-based, systems perspective by nursing faculty supports development of nurses who can function safely and effectively in the current health care system. [J Nurs Educ. 2017;56(11):679-682.]. Copyright 2017, SLACK Incorporated.

Using Blogging to Promote Clinical Reasoning and Metacognition in Undergraduate Physiotherapy Fieldwork Programs

ERIC Educational Resources Information Center

Tan, Shuyan Melissa; Ladyshewsky, Richard K.; Gardner, Peter

2010-01-01

This qualitative study investigated the impact of using blogs on the clinical reasoning and meta-cognitive skills of undergraduate physiotherapy students in a fieldwork education program. A blog is a web based document that enables individuals to enter comments and read each others' comments in a dynamic and interactive manner. In this study,…

Does Medical Students' Diagnostic Performance Improve by Observing Examples of Self-Explanation Provided by Peers or Experts?

ERIC Educational Resources Information Center

Chamberland, Martine; Mamede, Sílvia; St-Onge, Christina; Setrakian, Jean; Schmidt, Henk G.

2015-01-01

Educational strategies that promote the development of clinical reasoning in students remain scarce. Generating self-explanations (SE) engages students in active learning and has shown to be an effective technique to improve clinical reasoning in clerks. Example-based learning has been shown to support the development of accurate knowledge…

Students' Distributive Reasoning with Fractions and Unknowns

ERIC Educational Resources Information Center

Hackenberg, Amy J.; Lee, Mi Yeon

2016-01-01

To understand relationships between students' quantitative reasoning with fractions and their algebraic reasoning, a clinical interview study was conducted with 18 middle and high school students. The study included six students with each of three different multiplicative concepts, which are based on how students create and coordinate composite…

Fuzzy-Arden-Syntax-based, Vendor-agnostic, Scalable Clinical Decision Support and Monitoring Platform.

PubMed

Adlassnig, Klaus-Peter; Fehre, Karsten; Rappelsberger, Andrea

2015-01-01

This study's objective is to develop and use a scalable genuine technology platform for clinical decision support based on Arden Syntax, which was extended by fuzzy set theory and fuzzy logic. Arden Syntax is a widely recognized formal language for representing clinical and scientific knowledge in an executable format, and is maintained by Health Level Seven (HL7) International and approved by the American National Standards Institute (ANSI). Fuzzy set theory and logic permit the representation of knowledge and automated reasoning under linguistic and propositional uncertainty. These forms of uncertainty are a common feature of patients' medical data, the body of medical knowledge, and deductive clinical reasoning.

Longitudinal Assessment of Progress in Reasoning Capacity and Relation with Self-Estimation of Knowledge Base

ERIC Educational Resources Information Center

Collard, Anne; Mélot, France; Bourguignon, Jean-Pierre

2015-01-01

The aim of the study was to investigate progress in reasoning capacity and knowledge base appraisal in a longitudinal analysis of data from summative evaluation throughout a medical problem-based learning curriculum. The scores in multidisciplinary discussion of a clinical case and multiple choice questionnaires (MCQs) were studied longitudinally…

SAFETY: an integrated clinical reasoning and reflection framework for undergraduate nursing students.

PubMed

Hicks Russell, Bedelia; Geist, Melissa J; House Maffett, Jenny

2013-01-01

Nurse educators can no longer focus on imparting to students knowledge that is merely factual and content specific. Activities that provide students with opportunities to apply concepts in real-world scenarios can be powerful tools. Nurse educators should take advantage of student-patient interactions to model clinical reasoning and allow students to practice complex decision making throughout the entire curriculum. In response to this change in nursing education, faculty in a pediatric course designed a reflective clinical reasoning activity based on the SAFETY template, which is derived from the National Council of State Boards of Nursing RN practice analysis. Students were able to prioritize key components of nursing care, as well as integrate practice issues such as delegation, Health Insurance Portability and Accountability Act violations, and questioning the accuracy of orders. SAFETY is proposed as a framework for integration of content knowledge, clinical reasoning, and reflection on authentic professional nursing concerns. Copyright 2012, SLACK Incorporated.

Intelligent tutoring system for clinical reasoning skill acquisition in dental students.

PubMed

Suebnukarn, Siriwan

2009-10-01

Learning clinical reasoning is an important core activity of the modern dental curriculum. This article describes an intelligent tutoring system (ITS) for clinical reasoning skill acquisition. The system is designed to provide an experience that emulates that of live human-tutored problem-based learning (PBL) sessions as much as possible, while at the same time permitting the students to participate collaboratively from disparate locations. The system uses Bayesian networks to model individual student knowledge and activity, as well as that of the group. Tutoring algorithms use the models to generate tutoring hints. The system incorporates a multimodal interface that integrates text and graphics so as to provide a rich communication channel between the students and the system, as well as among students in the group. Comparison of learning outcomes shows that student clinical reasoning gains from the ITS are similar to those obtained from human-tutored sessions.

Erognomic education on housework for women with upper limb repetitive strain injury (RSI): a conceptual representation of therapists' clinical reasoning.

PubMed

Cheung, Therma W C; Clemson, Lindy; O' Loughlin, Kate; Shuttleworth, Russell

2017-09-18

Ergonomic education in housework that aims to facilitate behavior change is important for women with upper limb repetitive strain injury. Therapists usually conduct such programs based on implicit reasoning. Making this reasoning explicit is important in contributing to the profession's knowledge. To construct a conceptual representation of how occupational therapists make clinical decisions for such program. Based on a constructivist-grounded theory methodology, data were collected through in-depth interviewing with 14 occupational therapists from a major hospital in Singapore. Interviews were audiotaped and transcribed. Data was analyzed with line by line, focused and axial coding with constant data comparison throughout data collection. Therapists made clinical decisions based on their perceptions of their clients' behavior change in three stages: (i) listen; (ii) try; and (iii) persevere, bearing significant similarities to the transtheoretical theory of change. The study also showed that therapists may not have considered the full range of meanings that their clients attach to housework when interacting with them, a gap that needs to be addressed. The present study indicates the importance of therapists' understanding of the meanings that their clients attach to housework. Further research needs to address how to achieve this in a time-pressured clinical environment. Implications for Rehabilitation This study used qualitative research to demonstrate the process of translating therapists' tacit knowledge into an explicit form. It elucidates the following major implications for practice when therapists conduct ergonomic education to facilitate behavior change in housework for female homemakers with upper limb RSI:The conceptual framework of clinical reasoning constructed from the results can be used to increase therapists' awareness of how they make clinical decisions during an intervention. This framework can also be used for training new therapists. It is important for therapists to actively listen to their clients. Active listening will enable the therapists to understand and consider the personal meanings that these women attach to housework in order to facilitate a behavior change. Client-therapist interactions to facilitate clients' willingness to change should become a major focus in such a program. Similar research should be conducted in other clinical areas to develop explicit clinical reasoning frameworks to facilitate learning of novice therapists and reflection of experienced therapists to address any gap in their clinical reasoning.

A Study of the Efficacy of an Integrated Nutrition Assessment, Interviewing and Counseling, and Medical Nutrition Therapy (MNT) Course Utilizing Problem-Based Learning

ERIC Educational Resources Information Center

Stanczyk, Kathy K.

2014-01-01

Dietetics graduates have been argued to enter supervised professional practice, or a Dietetic Internship, with deficient clinical reasoning skills. Some researchers have suggested that one factor contributing to deficient clinical reasoning skills has been the fragmented course sequencing of a traditional dietetics curriculum, with multiple…

Justify Your Answer: The Role of Written Think Aloud in Script Concordance Testing.

PubMed

Power, Alyssa; Lemay, Jean-Francois; Cooke, Suzette

2017-01-01

Construct: Clinical reasoning assessment is a growing area of interest in the medical education literature. Script concordance testing (SCT) evaluates clinical reasoning in conditions of uncertainty and has emerged as an innovative tool in the domain of clinical reasoning assessment. SCT quantifies the degree of concordance between a learner and an experienced clinician and attempts to capture the breadth of responses of expert clinicians, acknowledging the significant yet acceptable variation in practice under situations of uncertainty. SCT has been shown to be a valid and reliable clinical reasoning assessment tool. However, as SCT provides only quantitative information, it may not provide a complete assessment of clinical reasoning. Think aloud (TA) is a qualitative research tool used in clinical reasoning assessment in which learners verbalize their thought process around an assigned task. This study explores the use of TA, in the form of written reflection, in SCT to assess resident clinical reasoning, hypothesizing that the information obtained from the written TA would enrich the quantitative data obtained through SCT. Ninety-one pediatric postgraduate trainees and 21 pediatricians from 4 Canadian training centers completed an online test consisting of 24 SCT cases immediately followed by retrospective written TA. Six of 24 cases were selected to gather TA data. These cases were chosen to allow all phases of clinical decision making (diagnosis, investigation, and treatment) to be represented in the TA data. Inductive thematic analysis was employed when systematically reviewing TA responses. Three main benefits of adding written TA to SCT were identified: (a) uncovering instances of incorrect clinical reasoning despite a correct SCT response, (b) revealing sound clinical reasoning in the context of a suboptimal SCT response, and (c) detecting question misinterpretation. Written TA can optimize SCT by demonstrating when correct examinee responses are based on guessing or uncertainty rather than robust clinical rationale. TA can also enhance SCT by allowing examinees to provide justification for responses that otherwise would have been considered incorrect and by identifying questions that are frequently misinterpreted to avoid including them in future examinations. TA also has significant value in differentiating between acceptable variations in expert clinician responses and deviance associated with faulty rationale or question misinterpretation; this could improve SCT reliability. A written TA protocol appears to be a valuable tool to assess trainees' clinical reasoning and can strengthen the quantitative assessment provided by SCT.

Clinical reasoning of nursing students on clinical placement: Clinical educators' perceptions.

PubMed

Hunter, Sharyn; Arthur, Carol

2016-05-01

Graduate nurses may have knowledge and adequate clinical psychomotor skills however they have been identified as lacking the clinical reasoning skills to deliver safe, effective care suggesting contemporary educational approaches do not always facilitate the development of nursing students' clinical reasoning. While nursing literature explicates the concept of clinical reasoning and develops models that demonstrate clinical reasoning, there is very little published about nursing students and clinical reasoning during clinical placements. Semi-structured interviews were conducted with ten clinical educators to gain an understanding of how they recognised, developed and appraised nursing students' clinical reasoning while on clinical placement. This study found variability in the clinical educators' conceptualisation, recognition, and facilitation of students' clinical reasoning. Although most of the clinical educators conceptualised clinical reasoning as a process those who did not demonstrated the greatest variability in the recognition and facilitation of students' clinical reasoning. The clinical educators in this study also described being unable to adequately appraise a student's clinical reasoning during clinical placement with the use of the current performance assessment tool. Copyright © 2016 Elsevier Ltd. All rights reserved.

Thinking like a nurse: a research-based model of clinical judgment in nursing.

PubMed

Tanner, Christine A

2006-06-01

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

An RDF/OWL knowledge base for query answering and decision support in clinical pharmacogenetics.

PubMed

Samwald, Matthias; Freimuth, Robert; Luciano, Joanne S; Lin, Simon; Powers, Robert L; Marshall, M Scott; Adlassnig, Klaus-Peter; Dumontier, Michel; Boyce, Richard D

2013-01-01

Genetic testing for personalizing pharmacotherapy is bound to become an important part of clinical routine. To address associated issues with data management and quality, we are creating a semantic knowledge base for clinical pharmacogenetics. The knowledge base is made up of three components: an expressive ontology formalized in the Web Ontology Language (OWL 2 DL), a Resource Description Framework (RDF) model for capturing detailed results of manual annotation of pharmacogenomic information in drug product labels, and an RDF conversion of relevant biomedical datasets. Our work goes beyond the state of the art in that it makes both automated reasoning as well as query answering as simple as possible, and the reasoning capabilities go beyond the capabilities of previously described ontologies.

Predicting the onset of psychosis in patients at clinical high risk: practical guide to probabilistic prognostic reasoning.

PubMed

Fusar-Poli, P; Schultze-Lutter, F

2016-02-01

Prediction of psychosis in patients at clinical high risk (CHR) has become a mainstream focus of clinical and research interest worldwide. When using CHR instruments for clinical purposes, the predicted outcome is but only a probability; and, consequently, any therapeutic action following the assessment is based on probabilistic prognostic reasoning. Yet, probabilistic reasoning makes considerable demands on the clinicians. We provide here a scholarly practical guide summarising the key concepts to support clinicians with probabilistic prognostic reasoning in the CHR state. We review risk or cumulative incidence of psychosis in, person-time rate of psychosis, Kaplan-Meier estimates of psychosis risk, measures of prognostic accuracy, sensitivity and specificity in receiver operator characteristic curves, positive and negative predictive values, Bayes' theorem, likelihood ratios, potentials and limits of real-life applications of prognostic probabilistic reasoning in the CHR state. Understanding basic measures used for prognostic probabilistic reasoning is a prerequisite for successfully implementing the early detection and prevention of psychosis in clinical practice. Future refinement of these measures for CHR patients may actually influence risk management, especially as regards initiating or withholding treatment. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Developing integrated clinical reasoning competencies in dental students using scaffolded case-based learning - empirical evidence.

PubMed

Postma, T C; White, J G

2016-08-01

This study provides empirical evidence of the development of integrated clinical reasoning in the discipline-based School of Dentistry, University of Pretoria, South Africa. Students were exposed to case-based learning in comprehensive patient care (CPC) in the preclinical year of study, scaffolded by means of the four-component instructional design model for complex learning. Progress test scores of third- to fifth-year dental students, who received case-based teaching and learning in the third year (2009-2011), were compared to the scores of preceding fourth- and fifth-year cohorts. These fourth- and fifth-year cohorts received content-based teaching concurrently with their clinical training in CPC. The progress test consisted of a complex case study and 32 MCQs on tracer conditions. Students had to gather the necessary information and had to make diagnostic and treatment-planning decisions. Preclinical students who participated in the case-based teaching and learning achieved similar scores compared to final-year students who received lecture-based teaching and learning. Final-year students who participated in the case-based learning made three more correct clinical decisions per student, compared to those who received content-based teaching. Students struggled more with treatment-planning than with diagnostic decisions. The scaffolded case-based learning appears to contribute to accurate clinical decisions when compared to lecture-based teaching. It is suggested that the development of integrated reasoning competencies starts as early as possible in a dental curriculum, perhaps even in the preclinical year of study. Treatment-planning should receive particular attention. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Causal role for inverse reasoning on obsessive-compulsive symptoms: Preliminary evidence from a cognitive bias modification for interpretation bias study.

PubMed

Wong, Shiu F; Grisham, Jessica R

2017-12-01

The inference-based approach (IBA) is a cognitive account of the genesis and maintenance of obsessive-compulsive disorder (OCD). According to the IBA, individuals with OCD are prone to using inverse reasoning, in which hypothetical causes form the basis of conclusions about reality. Several studies have provided preliminary support for an association between features of the IBA and OCD symptoms. However, there are currently no studies that have investigated the proposed causal relationship of inverse reasoning in OCD. In a non-clinical sample (N = 187), we used an interpretive cognitive bias procedure to train a bias towards using inverse reasoning (n = 64), healthy sensory-based reasoning (n = 65), or a control condition (n = 58). Participants were randomly allocated to these training conditions. This manipulation allowed us to assess whether, consistent with the IBA, inverse reasoning training increased compulsive-like behaviours and self-reported OCD symptoms. Results indicated that compared to a control condition, participants trained in inverse reasoning reported more OCD symptoms and were more avoidant of potentially contaminated objects. Moreover, change in inverse reasoning bias was a small but significant mediator of the relationship between training condition and behavioural avoidance. Conversely, training in a healthy (non-inverse) reasoning style did not have any effect on symptoms or behaviour relative to the control condition. As this study was conducted in a non-clinical sample, we were unable to generalise our findings to a clinical population. Findings generally support the IBA model by providing preliminary evidence of a causal role for inverse reasoning in OCD. Copyright © 2017 Elsevier Ltd. All rights reserved.

Part-whole reasoning in medical ontologies revisited--introducing SEP triplets into classification-based description logics.

PubMed

Schulz, S; Romacker, M; Hahn, U

1998-01-01

The development of powerful and comprehensive medical ontologies that support formal reasoning on a large scale is one of the key requirements for clinical computing in the next millennium. Taxonomic medical knowledge, a major portion of these ontologies, is mainly characterized by generalization and part-whole relations between concepts. While reasoning in generalization hierarchies is quite well understood, no fully conclusive mechanism as yet exists for part-whole reasoning. The approach we take emulates part-whole reasoning via classification-based reasoning using SEP triplets, a special data structure for encoding part-whole relations that is fully embedded in the formal framework of standard description logics.

Part-whole reasoning in medical ontologies revisited--introducing SEP triplets into classification-based description logics.

PubMed Central

Schulz, S.; Romacker, M.; Hahn, U.

1998-01-01

The development of powerful and comprehensive medical ontologies that support formal reasoning on a large scale is one of the key requirements for clinical computing in the next millennium. Taxonomic medical knowledge, a major portion of these ontologies, is mainly characterized by generalization and part-whole relations between concepts. While reasoning in generalization hierarchies is quite well understood, no fully conclusive mechanism as yet exists for part-whole reasoning. The approach we take emulates part-whole reasoning via classification-based reasoning using SEP triplets, a special data structure for encoding part-whole relations that is fully embedded in the formal framework of standard description logics. Images Figure 3 PMID:9929335

Why do adults entitled to free or highly subsidized dental services select fully out-of-pocket-paid care?

PubMed

Bayat, Fariborz; Vehkalahti, Miira M; Murtomaa, Heikki; Tala, Heikki

2010-02-01

To investigate patients' reasons for selecting a dental clinic given their choice of free or highly-subsidized dental services. The study was based on cross-sectional data obtained through phone interviews with adults in Tehran, Iran. The present study included those entitled to free or highly-subsidized dental services (n = 726). The data covered the patients' awareness of subsidized dental services and type of dental clinic for their most recent visit and their reasons for selecting that clinic. Awareness of subsidized dental services was dichotomized as being either aware or unaware of such subsidy. The type of clinic was dichotomized as providing either free or highly-subsidized (FHS) or fully out-of-pocket paid (FOP) services. Free format answers about the subjects' reasons for selecting a particular clinic were later sub-grouped as: convenient access, good technical aspects, good interpersonal aspects, low or reasonable fees, recommendation by a friend, and no reason. Socio-demographic status was based on background. Data analysis included the chi-square test and logistic regression model. Of the subjects (n = 726), 60% were women and 58% were under 35 years of age. The subjects' mean age was 33.5 years with no difference by gender (P = 0.24) and the majority had public insurance (91%). Of all the subjects, 60% selected FOP. Good interpersonal aspects were the strongest reason for selecting FOP (OR = 4.6), follow by good technical aspects (OR = 2.3). Those subjects who were unaware of their benefit had 4.6 times the odds of selecting FOP. Despite the opportunity to use highly-subsidized dental services, good interpersonal and good technical aspects lead patients to select private dentists and to pay fully out of pocket.

Implementation science: a role for parallel dual processing models of reasoning?

PubMed Central

Sladek, Ruth M; Phillips, Paddy A; Bond, Malcolm J

2006-01-01

Background A better theoretical base for understanding professional behaviour change is needed to support evidence-based changes in medical practice. Traditionally strategies to encourage changes in clinical practices have been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making. Discussion Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice. Summary It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice. PMID:16725023

Implementation science: a role for parallel dual processing models of reasoning?

PubMed

Sladek, Ruth M; Phillips, Paddy A; Bond, Malcolm J

2006-05-25

A better theoretical base for understanding professional behaviour change is needed to support evidence-based changes in medical practice. Traditionally strategies to encourage changes in clinical practices have been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making. Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice. It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice.

Pursuing Improvement in Clinical Reasoning: Development of the Clinical Coaching Interactions Inventory.

PubMed

Jessee, Mary Ann; Tanner, Christine A

2016-09-01

Clinical coaching has been identified as a signature pedagogy in nursing education. Recent findings indicate that clinical coaching interactions in the clinical learning environment fail to engage students in the higher order thinking skills believed to promote clinical reasoning. The Clinical Coaching Interactions Inventory (CCII) was based on evidence of supervisor questioning techniques, the Tanner clinical judgment model, Bloom's Taxonomy, and simulation evaluation tools. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Reliability was established with Kuder-Richardson Formula 20 (KR-20). CVI (S-CVI/Ave) was .91, and KR-20 was .70. The CCII identified differences in clinical coaching behaviors in university faculty supervisors and staff nurse preceptor supervisors. The CCII advances the measurement of clinical coaching interactions from qualitative to quantitative. Ultimately, results from use of this inventory may facilitate the design of prelicensure clinical coaching strategies that promote the improvement of students' clinical reasoning skill. [J Nurs Educ. 2016;55(9):495-504.]. Copyright 2016, SLACK Incorporated.

Development and initial evaluation of an instrument to assess physiotherapists' clinical reasoning focused on clients' behavior change.

PubMed

Elvén, Maria; Hochwälder, Jacek; Dean, Elizabeth; Söderlund, Anne

2018-05-01

A systematically developed and evaluated instrument is needed to support investigations of physiotherapists' clinical reasoning integrated with the process of clients' behavior change. This study's aim was to develop an instrument to assess physiotherapy students' and physiotherapists' clinical reasoning focused on clients' activity-related behavior and behavior change, and initiate its evaluation, including feasibility and content validity. The study was conducted in three phases: 1) determination of instrument structure and item generation, based on a model, guidelines for assessing clinical reasoning, and existing measures; 2) cognitive interviews with five physiotherapy students to evaluate item understanding and feasibility; and 3) a Delphi process with 18 experts to evaluate content relevance. Phase 1 resulted in an instrument with four domains: Physiotherapist; Input from client; Functional behavioral analysis; and Strategies for behavior change. The instrument consists of case scenarios followed by items in which key features are identified, prioritized, or interpreted. Phase 2 resulted in revisions of problems and approval of feasibility. Phase 3 demonstrated high level of consensus regarding the instrument's content relevance. This feasible and content-validated instrument shows potential for use in investigations of physiotherapy students' and physiotherapists' clinical reasoning, however continued development and testing are needed.

76 FR 1620 - Trials to Verify and Describe Clinical Benefit of Midodrine Hydrochloride; Establishment of...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-11

... a surrogate endpoint that is reasonably likely to predict clinical benefit or based on a clinical endpoint other than survival or irreversible morbidity. Approval of PROAMATINE was based on trials... surrogate endpoints are ``subject to the requirement that the applicant study the drug further to verify and...

Big-Data Based Decision-Support Systems to Improve Clinicians' Cognition.

PubMed

Roosan, Don; Samore, Matthew; Jones, Makoto; Livnat, Yarden; Clutter, Justin

2016-01-01

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians' cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems.

Big-Data Based Decision-Support Systems to Improve Clinicians’ Cognition

PubMed Central

Roosan, Don; Samore, Matthew; Jones, Makoto; Livnat, Yarden; Clutter, Justin

2016-01-01

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians’ cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems. PMID:27990498

The Effects of Mentored Problem-Based STEM Teaching on Pre-Service Elementary Teachers: Scientific Reasoning and Attitudes Toward STEM Subjects

NASA Astrophysics Data System (ADS)

Caliendo, Julia C.

Problem-based learning in clinical practice has become an integral part of many professional preparation programs. This quasi-experimental study compared the effect of a specialized 90-hour field placement on elementary pre-service teachers' scientific reasoning and attitudes towards teaching STEM (science, technology, engineering, and math) subjects. A cohort of 53 undergraduate elementary education majors, concurrent to their enrollment in science and math methods classes, were placed into one of two clinical practice experiences: (a) a university-based, problem-based learning (PBL), STEM classroom, or (b) a traditional public school classroom. Group gain scores on the Classroom Test of Scientific Reasoning (CTSR) and the Teacher Efficacy and Attitudes Toward STEM Survey-Elementary Teachers (T-STEM) survey were calculated. A MANCOVA revealed that there was a significant difference in gain scores between the treatment and comparison groups' scientific reasoning (p = .011) and attitudes towards teaching STEM subjects (p = .004). The results support the hypothesis that the pre-service elementary teachers who experienced STEM mentoring in a PBL setting will have an increase in their scientific reasoning and produce positive attitudes towards teaching STEM subjects. In addition, the results add to the existing research suggesting that elementary pre-service teachers require significant academic preparation and mentored support in STEM content.

Factors Influencing Retention Among Part-Time Clinical Nursing Faculty.

PubMed

Carlson, Joanne S

This study sought to determine job characteristics influencing retention of part-time clinical nurse faculty teaching in pre-licensure nursing education. Large numbers of part-time faculty are needed to educate students in the clinical setting. Faculty retention helps maintain consistency and may positively influence student learning. A national sample of part-time clinical nurse faculty teaching in baccalaureate programs responded to a web-based survey. Respondents were asked to identify the primary reason for wanting or not wanting to continue working for a school of nursing (SON). Affinity for students, pay and benefits, support, and feeling valued were the top three reasons given for continuing to work at an SON. Conflicts with life and other job responsibilities, low pay, and workload were the top three reasons given for not continuing. Results from this study can assist nursing programs in finding strategies to help reduce attrition among part-time clinical faculty.

Using functional neuroimaging combined with a think-aloud protocol to explore clinical reasoning expertise in internal medicine.

PubMed

Durning, Steven J; Graner, John; Artino, Anthony R; Pangaro, Louis N; Beckman, Thomas; Holmboe, Eric; Oakes, Terrance; Roy, Michael; Riedy, Gerard; Capaldi, Vincent; Walter, Robert; van der Vleuten, Cees; Schuwirth, Lambert

2012-09-01

Clinical reasoning is essential to medical practice, but because it entails internal mental processes, it is difficult to assess. Functional magnetic resonance imaging (fMRI) and think-aloud protocols may improve understanding of clinical reasoning as these methods can more directly assess these processes. The objective of our study was to use a combination of fMRI and think-aloud procedures to examine fMRI correlates of a leading theoretical model in clinical reasoning based on experimental findings to date: analytic (i.e., actively comparing and contrasting diagnostic entities) and nonanalytic (i.e., pattern recognition) reasoning. We hypothesized that there would be functional neuroimaging differences between analytic and nonanalytic reasoning theory. 17 board-certified experts in internal medicine answered and reflected on validated U.S. Medical Licensing Exam and American Board of Internal Medicine multiple-choice questions (easy and difficult) during an fMRI scan. This procedure was followed by completion of a formal think-aloud procedure. fMRI findings provide some support for the presence of analytic and nonanalytic reasoning systems. Statistically significant activation of prefrontal cortex distinguished answering incorrectly versus correctly (p < 0.01), whereas activation of precuneus and midtemporal gyrus distinguished not guessing from guessing (p < 0.01). We found limited fMRI evidence to support analytic and nonanalytic reasoning theory, as our results indicate functional differences with correct vs. incorrect answers and guessing vs. not guessing. However, our findings did not suggest one consistent fMRI activation pattern of internal medicine expertise. This model of employing fMRI correlates offers opportunities to enhance our understanding of theory, as well as improve our teaching and assessment of clinical reasoning, a key outcome of medical education.

Improving the learning of clinical reasoning through computer-based cognitive representation.

PubMed

Wu, Bian; Wang, Minhong; Johnson, Janice M; Grotzer, Tina A

2014-01-01

Objective Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Methods Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. Results A significant improvement was found in students' learning products from the beginning to the end of the study, consistent with students' report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. Conclusions The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction.

Improving the learning of clinical reasoning through computer-based cognitive representation

PubMed Central

Wu, Bian; Wang, Minhong; Johnson, Janice M.; Grotzer, Tina A.

2014-01-01

Objective Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Methods Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. Results A significant improvement was found in students’ learning products from the beginning to the end of the study, consistent with students’ report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. Conclusions The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction. PMID:25518871

Improving the learning of clinical reasoning through computer-based cognitive representation.

PubMed

Wu, Bian; Wang, Minhong; Johnson, Janice M; Grotzer, Tina A

2014-01-01

Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. A significant improvement was found in students' learning products from the beginning to the end of the study, consistent with students' report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction.

Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy.

PubMed

Baker, Sarah E; Painter, Elizabeth E; Morgan, Brandon C; Kaus, Anna L; Petersen, Evan J; Allen, Christopher S; Deyle, Gail D; Jensen, Gail M

2017-01-01

Clinical reasoning is essential to physical therapist practice. Solid clinical reasoning processes may lead to greater understanding of the patient condition, early diagnostic hypothesis development, and well-tolerated examination and intervention strategies, as well as mitigate the risk of diagnostic error. However, the complex and often subconscious nature of clinical reasoning can impede the development of this skill. Protracted tools have been published to help guide self-reflection on clinical reasoning but might not be feasible in typical clinical settings. This case illustrates how the Systematic Clinical Reasoning in Physical Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a physical therapist to search the literature to answer a clinical question and facilitate formal mentorship sessions in postprofessional physical therapist training programs. The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan the examination, query the literature to answer a clinical question, establish a physical therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the mentee's clinical reasoning and provided the mentor insight into the mentee's clinical reasoning. The reliability and validity of the SCRIPT tool have not been formally studied. Clinical mentorship is a cornerstone of postprofessional training programs and intended to develop advanced clinical reasoning skills. However, clinical reasoning is often subconscious and, therefore, a challenging skill to develop. The use of a tool such as the SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach to data gathering and making clinical judgments to bring clinical reasoning to the conscious level, facilitate self-reflection, and make a mentored physical therapist's thought processes explicit to his or her clinical mentor. © 2017 American Physical Therapy Association

Perspective: moving students beyond an organ-based approach when teaching medical interviewing and physical examination skills.

PubMed

Alexander, Erik K

2008-10-01

Medical interviewing and physical examination skills are core pillars of clinical medicine. Though nearly all U.S. medical students participate in preclinical courses designed to teach these skills, medical school faculty often comment that students' abilities remain limited on entering their clinical clerkships. The reason for this contention is not clear.The author briefly describes the current preclinical curricula at most medical schools that are designed to teach patient interviewing and examination. An organ-based curriculum is commonly employed, although the limitations of such an approach readily become apparent. For example, many hospitalized patients do not suffer from single-organ illnesses, but rather from infections or metabolic derangements, which cause numerous abnormalities to several body systems. Furthermore, clinical reasoning skills are rarely taught in such preclinical courses, though these abilities form the foundation for effective doctoring. These findings suggest an opportunity for content development surrounding patient interviewing and examination. The author proposes an educational approach that depicts how the confluence of both content knowledge skills and clinical reasoning skills can work synergistically to enhance preclinical teaching of the medical interview and physical examination.

Models of clinical reasoning with a focus on general practice: A critical review.

PubMed

Yazdani, Shahram; Hosseinzadeh, Mohammad; Hosseini, Fakhrolsadat

2017-10-01

Diagnosis lies at the heart of general practice. Every day general practitioners (GPs) visit patients with a wide variety of complaints and concerns, with often minor but sometimes serious symptoms. General practice has many features which differentiate it from specialty care setting, but during the last four decades little attention was paid to clinical reasoning in general practice. Therefore, we aimed to critically review the clinical reasoning models with a focus on the clinical reasoning in general practice or clinical reasoning of general practitioners to find out to what extent the existing models explain the clinical reasoning specially in primary care and also identity the gaps of the model for use in primary care settings. A systematic search to find models of clinical reasoning were performed. To have more precision, we excluded the studies that focused on neurobiological aspects of reasoning, reasoning in disciplines other than medicine decision making or decision analysis on treatment or management plan. All the articles and documents were first scanned to see whether they include important relevant contents or any models. The selected studies which described a model of clinical reasoning in general practitioners or with a focus on general practice were then reviewed and appraisal or critics of other authors on these models were included. The reviewed documents on the model were synthesized. Six models of clinical reasoning were identified including hypothetic-deductive model, pattern recognition, a dual process diagnostic reasoning model, pathway for clinical reasoning, an integrative model of clinical reasoning, and model of diagnostic reasoning strategies in primary care. Only one model had specifically focused on general practitioners reasoning. A Model of clinical reasoning that included specific features of general practice to better help the general practitioners with the difficulties of clinical reasoning in this setting is needed.

Case-based clinical reasoning in feline medicine: 1: Intuitive and analytical systems.

PubMed

Canfield, Paul J; Whitehead, Martin L; Johnson, Robert; O'Brien, Carolyn R; Malik, Richard

2016-01-01

This is Article 1 of a three-part series on clinical reasoning that encourages practitioners to explore and understand how they think and make case-based decisions. It is hoped that, in the process, they will learn to trust their intuition but, at the same time, put in place safeguards to diminish the impact of bias and misguided logic on their diagnostic decision-making. This first article discusses the relative merits and shortcomings of System 1 thinking (immediate and unconscious) and System 2 thinking (effortful and analytical). Articles 2 and 3, to appear in the March and May 2016 issues of JFMS, respectively, will examine managing cognitive error, and use of heuristics (mental short cuts) and illness scripts in diagnostic reasoning. © The Author(s) 2016.

Effects of additional team-based learning on students' clinical reasoning skills: a pilot study.

PubMed

Jost, Meike; Brüstle, Peter; Giesler, Marianne; Rijntjes, Michel; Brich, Jochen

2017-07-14

In the field of Neurology good clinical reasoning skills are essential for successful diagnosing and treatment. Team-based learning (TBL), an active learning and small group instructional strategy, is a promising method for fostering these skills. The aim of this pilot study was to examine the effects of a supplementary TBL-class on students' clinical decision-making skills. Fourth- and fifth-year medical students participated in this pilot study (static-group comparison design). The non-treatment group (n = 15) did not receive any additional training beyond regular teaching in the neurology course. The treatment group (n = 11) took part in a supplementary TBL-class optimized for teaching clinical reasoning in addition to the regular teaching in the neurology course. Clinical decision making skills were assessed using a key-feature problem examination. Factual and conceptual knowledge was assessed by a multiple-choice question examination. The TBL-group performed significantly better than the non-TBL-group (p = 0.026) in the key-feature problem examination. No significant differences between the results of the multiple-choice question examination of both groups were found. In this pilot study participants of a supplementary TBL-class significantly improved clinical decision-making skills, indicating that TBL may be an appropriate method for teaching clinical decision making in neurology. Further research is needed for replication in larger groups and other clinical fields.

How to tell a patient's story? Influence of the case narrative design on the clinical reasoning process in virtual patients.

PubMed

Hege, Inga; Dietl, Anita; Kiesewetter, Jan; Schelling, Jörg; Kiesewetter, Isabel

2018-02-28

Virtual patients (VPs) are narrative-based educational activities to train clinical reasoning in a safe environment. Our aim was to explore the influence of the design of the narrative and level of difficulty on the clinical reasoning process, diagnostic accuracy and time-on-task. In a randomized controlled trial, we analyzed the clinical reasoning process of 46 medical students with six VPs in three different variations: (1) patients showing a friendly behavior, (2) patients showing a disruptive behavior and (3) a version without a patient story. For easy VPs, we did not see a significant difference in diagnostic accuracy. For difficult VPs, the diagnostic accuracy was significantly higher for participants who worked on the friendly VPs compared to the other two groups. Independent from VP difficulty, participants identified significantly more problems and tests for disruptive than for friendly VPs; time on task was comparable for these two groups. The extrinsic motivation of participants working on the VPs without a patient story was significantly lower than for the students working on the friendly VPs. Our results indicate that the measured VP difficulty has a higher influence on the clinical reasoning process and diagnostic accuracy than the variations in the narratives.

Pursuing Improvement in Clinical Reasoning: The Integrated Clinical Education Theory.

PubMed

Jessee, Mary Ann

2018-01-01

The link between clinical education and development of clinical reasoning is not well supported by one theoretical perspective. Learning to reason during clinical education may be best achieved in a supportive sociocultural context of nursing practice that maximizes reasoning opportunities and facilitates discourse and meaningful feedback. Prelicensure clinical education seldom incorporates these critical components and thus may fail to directly promote clinical reasoning skill. Theoretical frameworks supporting the development of clinical reasoning during clinical education were evaluated. Analysis of strengths and gaps in each framework's support of clinical reasoning development was conducted. Commensurability of philosophical underpinnings was confirmed, and complex relationships among key concepts were elucidated. Six key concepts and three tenets comprise an explanatory predictive theory-the integrated clinical education theory (ICET). ICET provides critical theoretical support for inquiry and action to promote clinical education that improves development of clinical reasoning skill. [J Nurs Educ. 2018;57(1):7-13.]. Copyright 2018, SLACK Incorporated.

The Edwin Smith papyrus: a clinical reappraisal of the oldest known document on spinal injuries

PubMed Central

Sanchez, Gonzalo M.; Burridge, Alwyn L.

2010-01-01

Dating from the seventeenth century b.c. the Edwin Smith papyrus is a unique treatise containing the oldest known descriptions of signs and symptoms of injuries of the spinal column and spinal cord. Based on a recent “medically based translation” of the Smith papyrus, its enclosed treasures in diagnostic, prognostic and therapeutic reasoning are revisited. Although patient demographics, diagnostic techniques and therapeutic options considerably changed over time, the documented rationale on spinal injuries can still be regarded as the state-of-the-art reasoning for modern clinical practice. PMID:20697750

Why do clinicians choose the therapies and techniques they do? Exploring clinical decision-making via treatment selections in dysphagia practice.

PubMed

McCurtin, Arlene; Healy, Chiara

2017-02-01

Speech-language pathologists (SLPs) are assumed to use evidence-based practice to inform treatment decisions. However, the reasoning underpinning treatment selections is not well known. Understanding why SLPs choose the treatments they do may be clarified by exploring the reasoning tied to specific treatments such as dysphagia interventions. An electronic survey methodology was utilised. Participants were accessed via the gatekeepers of two national dysphagia special interest groups representing adult and paediatric populations. Information was elicited on the dysphagia therapies and techniques used and on the reasoning for using/not using therapies. Data was analysed using descriptive and non-parametric statistics. The survey had a 74.8% response rate (n = 116). Consensus in both treatment selections and reasoning supporting treatment decisions was evident. Three favoured interventions (texture modification, thickening liquids, positioning changes) were identified. The reasoning supporting treatment choices centred primarily on client suitability and clinician knowledge. Knowledge reflected both absent knowledge (e.g. training) and accumulated knowledge (clinical experience). Dysphagia practice appears highly-defined, being characterised by group consensus regarding both preferred treatments and the reasoning underpinning treatment selections. Treatment selections are based on two core criteria: client suitability and the SLPs experience/knowledge. Explicit scientific reasoning is less influential than practice-centric influences.

Clinician Documentation on Receipt of Trauma-Focused Evidence-Based Psychotherapies in a VA PTSD Clinic.

PubMed

Lu, Mary W; Plagge, Jane M; Marsiglio, Mary C; Dobscha, Steven K

2016-01-01

The U.S. Department of Veterans Affairs (VA) is implementing two trauma-focused, evidence-based psychotherapies (TF-EBPs) for posttraumatic stress disorder (PTSD): cognitive processing therapy and prolonged exposure therapy (PE). Veterans with PTSD often do not receive these treatments, and little is known about the reasons veterans may not receive TF-EBPs. The aim of this qualitative study was to summarize clinician-reported reasons in medical records for nonreceipt of TF-EBPs. All veterans (N = 63) identified through PTSD screening who were newly engaged in mental health care and received individual evaluations in a PTSD specialty clinic in fiscal year 2008 were included in the sample. Content analysis of electronic medical records revealed multiple potential reasons for nonreceipt of TF-EBPs including referral to other PTSD treatments, other clinical priorities, poor engagement in care, practical barriers, negative beliefs, and receipt of care in other settings. Eight veterans (13%) initiated TF-EBPs. Further interventions to promote engagement in PTSD treatment are warranted.

Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach.

PubMed

Geng, Elvin H; Bangsberg, David R; Musinguzi, Nicolas; Emenyonu, Nneka; Bwana, Mwebesa Bosco; Yiannoutsos, Constantin T; Glidden, David V; Deeks, Steven G; Martin, Jeffrey N

2010-03-01

Losses to follow-up after initiation of antiretroviral therapy (ART) are common in Africa and are a considerable obstacle to understanding the effectiveness of nascent treatment programs. We sought to characterize, through a sampling-based approach, reasons for and outcomes of patients who become lost to follow-up. Cohort study. We searched for and interviewed a representative sample of lost patients or close informants in the community to determine reasons for and outcomes among lost patients. Three thousand six hundred twenty-eight HIV-infected adults initiated ART between January 1, 2004 and September 30, 2007 in Mbarara, Uganda. Eight hundred twenty-nine became lost to follow-up (cumulative incidence at 1, 2, and 3 years of 16%, 30%, and 39%). We sought a representative sample of 128 lost patients in the community and ascertained vital status in 111 (87%). Top reasons for loss included lack of transportation or money and work/child care responsibilities. Among the 111 lost patients who had their vital status ascertained through tracking, 32 deaths occurred (cumulative 1-year incidence 36%); mortality was highest shortly after the last clinic visit. Lower pre-ART CD4 T-cell count, older age, low blood pressure, and a central nervous system syndrome at the last clinic visit predicted deaths. Of patients directly interviewed, 83% were in care at another clinic and 71% were still using ART. Sociostructural factors are the primary reasons for loss to follow-up. Outcomes among the lost are heterogeneous: both deaths and transfers to other clinics were common. Tracking a sample of lost patients is an efficient means for programs to understand site-specific reasons for and outcomes among patients lost to follow-up.

Promoting Therapists' Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation.

PubMed

Levac, Danielle E; Glegg, Stephanie M N; Sveistrup, Heidi; Colquhoun, Heather; Miller, Patricia; Finestone, Hillel; DePaul, Vincent; Harris, Jocelyn E; Velikonja, Diana

2016-01-01

Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists' confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists' perspectives on MLS use during VR-based therapy provision. The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists' clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. The KT intervention improved therapists' confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.

Promoting Therapists’ Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation

PubMed Central

Levac, Danielle E.; Glegg, Stephanie M. N.; Sveistrup, Heidi; Colquhoun, Heather; Miller, Patricia; Finestone, Hillel; DePaul, Vincent; Harris, Jocelyn E.; Velikonja, Diana

2016-01-01

Purpose Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. Method A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists’ confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists’ perspectives on MLS use during VR-based therapy provision. Results The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists’ clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. Conclusion The KT intervention improved therapists’ confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy. PMID:27992492

Why do we do as we do? Factors influencing clinical reasoning and decision-making among physiotherapists in an acute setting.

PubMed

Holdar, Ulrika; Wallin, Lars; Heiwe, Susanne

2013-12-01

Despite the current movement for health-care to become more informed by evidence, knowledge on effective implementation of evidence-based practice is scarce. To improve research application among physiotherapists, the process of implementation and clinical reasoning needs to be scrutinized. The aim of this study was to identify various experiences of factors that influence the physiotherapist's clinical reasoning in specialist care. A phenomenographic approach was chosen. Eleven physiotherapists at two acute care hospitals in nn. Data was obtained by observations and interviews. Phenomenographic data analysis identified various experiences of clinical decision-making. The Ethical Review Board of the nn approved the study. The observations and the interviews enabled identification of various experiences that influenced clinical decision-making. The physiotherapists' clinical reasoning was perceived to be constrained by contextual factors. The physiotherapists collected current information on the patient by using written and verbal information exchange and used this to generate an inner picture of the patient. By creating hypotheses that were accepted or rejected, they made decisions in advance of their interventions. The decisions were influenced by the individual characteristics of the physiotherapist, his/her knowledge and patient perceptions. Clinical reasoning is a complex and constantly evolving process. Contextual factors such as economy and politics are not easily changed, but factors such as the patient and the physiotherapist as a person are more tangible. Copyright © 2013 John Wiley & Sons, Ltd.

Prelicensure Baccalaureate Nursing Students' Perceptions of Their Development of Clinical Reasoning.

PubMed

Herron, Elizabeth K; Sudia, Tanya; Kimble, Laura P; Davis, Alison H

2016-06-01

Establishing a strong foundation for the development of clinical reasoning in nursing students is essential to ensure safe and effective patient care. This study explored prelicensure baccalaureate nursing students' perceptions of their development of clinical reasoning, as well as their perceptions of how it is taught. In this phenomenological study, individual semistructured interviews were conducted to gather data related to participants' perceptions of their development of clinical reasoning. Data were analyzed using procedural steps delineated by Giorgi. Data analysis revealed three main themes: Instructor Characteristics, Importance of Clinical Reasoning, and Best Place to Learn Clinical Reasoning. Students recognized how clinical reasoning enhances safe and effective clinical practice and indicated the clinical arena was the most beneficial environment in which to learn clinical reasoning. Understanding students' perceptions of learning benefits nurse educators in planning nursing program curricula to enhance and facilitate the development of clinical reasoning. [J Nurs Educ. 2016;55(6):329-335.]. Copyright 2016, SLACK Incorporated.

Models of clinical reasoning with a focus on general practice: A critical review

PubMed Central

YAZDANI, SHAHRAM; HOSSEINZADEH, MOHAMMAD; HOSSEINI, FAKHROLSADAT

2017-01-01

Introduction: Diagnosis lies at the heart of general practice. Every day general practitioners (GPs) visit patients with a wide variety of complaints and concerns, with often minor but sometimes serious symptoms. General practice has many features which differentiate it from specialty care setting, but during the last four decades little attention was paid to clinical reasoning in general practice. Therefore, we aimed to critically review the clinical reasoning models with a focus on the clinical reasoning in general practice or clinical reasoning of general practitioners to find out to what extent the existing models explain the clinical reasoning specially in primary care and also identity the gaps of the model for use in primary care settings. Methods: A systematic search to find models of clinical reasoning were performed. To have more precision, we excluded the studies that focused on neurobiological aspects of reasoning, reasoning in disciplines other than medicine decision making or decision analysis on treatment or management plan. All the articles and documents were first scanned to see whether they include important relevant contents or any models. The selected studies which described a model of clinical reasoning in general practitioners or with a focus on general practice were then reviewed and appraisal or critics of other authors on these models were included. The reviewed documents on the model were synthesized. Results: Six models of clinical reasoning were identified including hypothetic-deductive model, pattern recognition, a dual process diagnostic reasoning model, pathway for clinical reasoning, an integrative model of clinical reasoning, and model of diagnostic reasoning strategies in primary care. Only one model had specifically focused on general practitioners reasoning. Conclusion: A Model of clinical reasoning that included specific features of general practice to better help the general practitioners with the difficulties of clinical reasoning in this setting is needed. PMID:28979912

A case-based reasoning tool for breast cancer knowledge management with data mining concepts and techniques

NASA Astrophysics Data System (ADS)

Demigha, Souâd.

2016-03-01

The paper presents a Case-Based Reasoning Tool for Breast Cancer Knowledge Management to improve breast cancer screening. To develop this tool, we combine both concepts and techniques of Case-Based Reasoning (CBR) and Data Mining (DM). Physicians and radiologists ground their diagnosis on their expertise (past experience) based on clinical cases. Case-Based Reasoning is the process of solving new problems based on the solutions of similar past problems and structured as cases. CBR is suitable for medical use. On the other hand, existing traditional hospital information systems (HIS), Radiological Information Systems (RIS) and Picture Archiving Information Systems (PACS) don't allow managing efficiently medical information because of its complexity and heterogeneity. Data Mining is the process of mining information from a data set and transform it into an understandable structure for further use. Combining CBR to Data Mining techniques will facilitate diagnosis and decision-making of medical experts.

The IDEA Assessment Tool: Assessing the Reporting, Diagnostic Reasoning, and Decision-Making Skills Demonstrated in Medical Students' Hospital Admission Notes.

PubMed

Baker, Elizabeth A; Ledford, Cynthia H; Fogg, Louis; Way, David P; Park, Yoon Soo

2015-01-01

Construct: Clinical skills are used in the care of patients, including reporting, diagnostic reasoning, and decision-making skills. Written comprehensive new patient admission notes (H&Ps) are a ubiquitous part of student education but are underutilized in the assessment of clinical skills. The interpretive summary, differential diagnosis, explanation of reasoning, and alternatives (IDEA) assessment tool was developed to assess students' clinical skills using written comprehensive new patient admission notes. The validity evidence for assessment of clinical skills using clinical documentation following authentic patient encounters has not been well documented. Diagnostic justification tools and postencounter notes are described in the literature (1,2) but are based on standardized patient encounters. To our knowledge, the IDEA assessment tool is the first published tool that uses medical students' H&Ps to rate students' clinical skills. The IDEA assessment tool is a 15-item instrument that asks evaluators to rate students' reporting, diagnostic reasoning, and decision-making skills based on medical students' new patient admission notes. This study presents validity evidence in support of the IDEA assessment tool using Messick's unified framework, including content (theoretical framework), response process (interrater reliability), internal structure (factor analysis and internal-consistency reliability), and relationship to other variables. Validity evidence is based on results from four studies conducted between 2010 and 2013. First, the factor analysis (2010, n = 216) yielded a three-factor solution, measuring patient story, IDEA, and completeness, with reliabilities of .79, .88, and .79, respectively. Second, an initial interrater reliability study (2010) involving two raters demonstrated fair to moderate consensus (κ = .21-.56, ρ =.42-.79). Third, a second interrater reliability study (2011) with 22 trained raters also demonstrated fair to moderate agreement (intraclass correlations [ICCs] = .29-.67). There was moderate reliability for all three skill domains, including reporting skills (ICC = .53), diagnostic reasoning skills (ICC = .64), and decision-making skills (ICC = .63). Fourth, there was a significant correlation between IDEA rating scores (2010-2013) and final Internal Medicine clerkship grades (r = .24), 95% confidence interval (CI) [.15, .33]. The IDEA assessment tool is a novel tool with validity evidence to support its use in the assessment of students' reporting, diagnostic reasoning, and decision-making skills. The moderate reliability achieved supports formative or lower stakes summative uses rather than high-stakes summative judgments.

"Clinical Reasoning Theater": A New Approach to Clinical Reasoning Education.

ERIC Educational Resources Information Center

Borleffs, Jan C. C.; Custers, Eugene J. F. M.; van Gijn, Jan; ten Gate, Olle Th. J.

2003-01-01

Describes a new approach to clinical reasoning education called clinical reasoning theater (CRT). With students as the audience, the doctor's clinical reasoning skills are modeled in CRT when he or she thinks aloud during conversations with the patient. Preliminary results of students' evaluations of the relevance of CRT reveal that they…

Evidence in clinical reasoning: a computational linguistics analysis of 789,712 medical case summaries 1983-2012.

PubMed

Seidel, Bastian M; Campbell, Steven; Bell, Erica

2015-03-21

Better understanding of clinical reasoning could reduce diagnostic error linked to 8% of adverse medical events and 30% of malpractice cases. To a greater extent than the evidence-based movement, the clinical reasoning literature asserts the importance of practitioner intuition—unconscious elements of diagnostic reasoning. The study aimed to analyse the content of case report summaries in ways that explored the importance of an evidence concept, not only in relation to research literature but also intuition. The study sample comprised all 789,712 abstracts in English for case reports contained in the database PUBMED for the period 1 January 1983 to 31 December 2012. It was hypothesised that, if evidence and intuition concepts were viewed by these clinical authors as essential to understanding their case reports, they would be more likely to be found in the abstracts. Computational linguistics software was used in 1) concept mapping of 21,631,481 instances of 201 concepts, and 2) specific concept analyses examining 200 paired co-occurrences for 'evidence' and research 'literature' concepts. 'Evidence' is a fundamentally patient-centred, intuitive concept linked to less common concepts about underlying processes, suspected disease mechanisms and diagnostic hunches. In contrast, the use of research literature in clinical reasoning is linked to more common reasoning concepts about specific knowledge and descriptions or presenting features of cases. 'Literature' is by far the most dominant concept, increasing in relevance since 2003, with an overall relevance of 13% versus 5% for 'evidence' which has remained static. The fact that the least present types of reasoning concepts relate to diagnostic hunches to do with underlying processes, such as what is suspected, raises questions about whether intuitive practitioner evidence-making, found in a constellation of dynamic, process concepts, has become less important. The study adds support to the existing corpus of research on clinical reasoning, by suggesting that intuition involves a complex constellation of concepts important to how the construct of evidence is understood. The list of concepts the study generated offers a basis for reflection on the nature of evidence in diagnostic reasoning and the importance of intuition to that reasoning.

Context Impact of Clinical Scenario on Knowledge Transfer and Reasoning Capacity in a Medical Problem-Based Learning Curriculum

ERIC Educational Resources Information Center

Collard, A.; Brédart, S.; Bourguignon, J.-P.

2016-01-01

Since 2000, the faculty of Medicine at the University of Liège has integrated problem-based learning (PBL) seminars from year two to seven in its seven-year curriculum. The PBL approach has been developed to facilitate students' acquisition of reasoning capacity. This contextualized learning raises the question of the de- and re-contextualization…

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

PubMed Central

Musgrove, John L.; Morris, Jason; Estrada, Carlos A.; Kraemer, Ryan R.

2016-01-01

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms. PMID:27168884

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

PubMed

Musgrove, John L; Morris, Jason; Estrada, Carlos A; Kraemer, Ryan R

2016-05-01

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.

Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study.

PubMed

Jefford, Elaine; Fahy, Kathleen

2015-05-01

clinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from 'non-scientific' occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology. to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour? twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted. using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data. over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes 'intuition' as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated. Copyright © 2015 Elsevier Ltd. All rights reserved.

Model of critical diagnostic reasoning: achieving expert clinician performance.

PubMed

Harjai, Prashant Kumar; Tiwari, Ruby

2009-01-01

Diagnostic reasoning refers to the analytical processes used to determine patient health problems. While the education curriculum and health care system focus on training nurse clinicians to accurately recognize and rescue clinical situations, assessments of non-expert nurses have yielded less than satisfactory data on diagnostic competency. The contrast between the expert and non-expert nurse clinician raises the important question of how differences in thinking may contribute to a large divergence in accurate diagnostic reasoning. This article recognizes superior organization of one's knowledge base, using prototypes, and quick retrieval of pertinent information, using similarity recognition as two reasons for the expert's superior diagnostic performance. A model of critical diagnostic reasoning, using prototypes and similarity recognition, is proposed and elucidated using case studies. This model serves as a starting point toward bridging the gap between clinical data and accurate problem identification, verification, and management while providing a structure for a knowledge exchange between expert and non-expert clinicians.

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

PubMed

Abuzour, Aseel S; Lewis, Penny J; Tully, Mary P

2018-03-01

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Functional neuroimaging correlates of thinking flexibility and knowledge structure in memory: Exploring the relationships between clinical reasoning and diagnostic thinking.

PubMed

Durning, Steven J; Costanzo, Michelle E; Beckman, Thomas J; Artino, Anthony R; Roy, Michael J; van der Vleuten, Cees; Holmboe, Eric S; Lipner, Rebecca S; Schuwirth, Lambert

2016-06-01

Diagnostic reasoning involves the thinking steps up to and including arrival at a diagnosis. Dual process theory posits that a physician's thinking is based on both non-analytic or fast, subconscious thinking and analytic thinking that is slower, more conscious, effortful and characterized by comparing and contrasting alternatives. Expertise in clinical reasoning may relate to the two dimensions measured by the diagnostic thinking inventory (DTI): memory structure and flexibility in thinking. Explored the functional magnetic resonance imaging (fMRI) correlates of these two aspects of the DTI: memory structure and flexibility of thinking. Participants answered and reflected upon multiple-choice questions (MCQs) during fMRI. A DTI was completed shortly after the scan. The brain processes associated with the two dimensions of the DTI were correlated with fMRI phases - assessing flexibility in thinking during analytical clinical reasoning, memory structure during non-analytical clinical reasoning and the total DTI during both non-analytical and analytical reasoning in experienced physicians. Each DTI component was associated with distinct functional neuroanatomic activation patterns, particularly in the prefrontal cortex. Our findings support diagnostic thinking conceptual models and indicate mechanisms through which cognitive demands may induce functional adaptation within the prefrontal cortex. This provides additional objective validity evidence for the use of the DTI in medical education and practice settings.

Validity and usability of a professional association's web-based knowledge translation portal: American Physical Therapy Association's PTNow.org.

PubMed

Deutsch, Judith E; Romney, Wendy; Reynolds, Jan; Manal, Tara Jo

2015-10-08

PTNow.org is an evidence-based, on-line portal created by a professional membership association to promote use of evidence in practice and to help decrease unwarranted variation in practice. The site contains synthesis documents designed to promote efficient clinical reasoning. These documents were written and peer-reviewed by teams of content experts and master clinicians. The purpose of this paper is to report on the content and construct validity as well as usability of the site. Physical therapist participants used clinical summaries (available in 3 formats--as a full summary with hyperlinks, "quick takes" with hyperlinks, and a portable two-page version) on the PTNow.org site to answer knowledge acquisition and clinical reasoning questions related to four patient scenarios. They also responded to questions about ease of use related to website navigation and about format and completeness of information using a 1-5 Likert scale. Responses were coded to reflect how participants used the site and then were summarized descriptively. Preferences for clinical summary format were analyzed using an analysis of variance (ANOVA) and a Dunnett T3 post hoc analysis. Seventeen participants completed the study. Clinical relevance and completeness ratings by experienced clinicians, which were used as the measure of content validity, ranged from 3.1 to 4.6 on a 5 point scale. Construct validity based on the information on the PTNow.org site was supported for knowledge acquisition questions 66 % of the time and for clinical reasoning questions 40 % of the time. Usability ratings for the full clinical summary were 4.6 (1.2); for the quick takes, 3.5 (.98); and for the portable clinical summary, 4.0 (.45). Participants preferred the full clinical summary over the other two formats (F = 5.908, P = 0.007). One hundred percent of the participants stated that they would recommend the PTNow site to their colleagues. Prelimary evidence supported both content validity and construct validity of knowledge acquisition, and partially supported construct validity of clinical reasoning for the clinical summaries on the PTNow.org site. Usability was supported, with users preferring the full clinical summary over the other two formats. Iterative design is ongoing.

Community-based dental education: history, current status, and future.

PubMed

Formicola, Allan J; Bailit, Howard L

2012-01-01

This article examines the history, current status, and future direction of community-based dental education (CBDE). The key issues addressed include the reasons that dentistry developed a different clinical education model than the other health professions; how government programs, private medical foundations, and early adopter schools influenced the development of CBDE; the societal and financial factors that are leading more schools to increase the time that senior dental students spend in community programs; the impact of CBDE on school finances and faculty and student perceptions; and the reasons that CBDE is likely to become a core part of the clinical education of all dental graduates.

Assessing clinical reasoning (ASCLIRE): Instrument development and validation.

PubMed

Kunina-Habenicht, Olga; Hautz, Wolf E; Knigge, Michel; Spies, Claudia; Ahlers, Olaf

2015-12-01

Clinical reasoning is an essential competency in medical education. This study aimed at developing and validating a test to assess diagnostic accuracy, collected information, and diagnostic decision time in clinical reasoning. A norm-referenced computer-based test for the assessment of clinical reasoning (ASCLIRE) was developed, integrating the entire clinical decision process. In a cross-sectional study participants were asked to choose as many diagnostic measures as they deemed necessary to diagnose the underlying disease of six different cases with acute or sub-acute dyspnea and provide a diagnosis. 283 students and 20 content experts participated. In addition to diagnostic accuracy, respective decision time and number of used relevant diagnostic measures were documented as distinct performance indicators. The empirical structure of the test was investigated using a structural equation modeling approach. Experts showed higher accuracy rates and lower decision times than students. In a cross-sectional comparison, the diagnostic accuracy of students improved with the year of study. Wrong diagnoses provided by our sample were comparable to wrong diagnoses in practice. We found an excellent fit for a model with three latent factors-diagnostic accuracy, decision time, and choice of relevant diagnostic information-with diagnostic accuracy showing no significant correlation with decision time. ASCLIRE considers decision time as an important performance indicator beneath diagnostic accuracy and provides evidence that clinical reasoning is a complex ability comprising diagnostic accuracy, decision time, and choice of relevant diagnostic information as three partly correlated but still distinct aspects.

Clinical Reasoning: Survey of Teaching Methods, Integration, and Assessment in Entry-Level Physical Therapist Academic Education.

PubMed

Christensen, Nicole; Black, Lisa; Furze, Jennifer; Huhn, Karen; Vendrely, Ann; Wainwright, Susan

2017-02-01

Although clinical reasoning abilities are important learning outcomes of physical therapist entry-level education, best practice standards have not been established to guide clinical reasoning curricular design and learning assessment. This research explored how clinical reasoning is currently defined, taught, and assessed in physical therapist entry-level education programs. A descriptive, cross-sectional survey was administered to physical therapist program representatives. An electronic 24-question survey was distributed to the directors of 207 programs accredited by the Commission on Accreditation in Physical Therapy Education. Descriptive statistical analysis and qualitative content analysis were performed. Post hoc demographic and wave analyses revealed no evidence of nonresponse bias. A response rate of 46.4% (n=96) was achieved. All respondents reported that their programs incorporated clinical reasoning into their curricula. Only 25% of respondents reported a common definition of clinical reasoning in their programs. Most respondents (90.6%) reported that clinical reasoning was explicit in their curricula, and 94.8% indicated that multiple methods of curricular integration were used. Instructor-designed materials were most commonly used to teach clinical reasoning (83.3%). Assessment of clinical reasoning included practical examinations (99%), clinical coursework (94.8%), written examinations (87.5%), and written assignments (83.3%). Curricular integration of clinical reasoning-related self-reflection skills was reported by 91%. A large number of incomplete surveys affected the response rate, and the program directors to whom the survey was sent may not have consulted the faculty members who were most knowledgeable about clinical reasoning in their curricula. The survey construction limited some responses and application of the results. Although clinical reasoning was explicitly integrated into program curricula, it was not consistently defined, taught, or assessed within or between the programs surveyed-resulting in significant variability in clinical reasoning education. These findings support the need for the development of best educational practices for clinical reasoning curricula and learning assessment. © 2017 American Physical Therapy Association

Reasoning and Data Representation in a Health and Lifestyle Support System.

PubMed

Hanke, Sten; Kreiner, Karl; Kropf, Johannes; Scase, Marc; Gossy, Christian

2017-01-01

Case-based reasoning and data interpretation is an artificial intelligence approach that capitalizes on past experience to solve current problems and this can be used as a method for practical intelligent systems. Case-based data reasoning is able to provide decision support for experts and clinicians in health systems as well as lifestyle systems. In this project we were focusing on developing a solution for healthy ageing considering daily activities, nutrition as well as cognitive activities. The data analysis of the reasoner followed state of the art guidelines from clinical practice. Guidelines provide a general framework to guide clinicians, and require consequent background knowledge to become operational, which is precisely the kind of information recorded in practice cases; cases complement guidelines very well and helps to interpret them. It is expected that the interest in case-based reasoning systems in the health.

Regression of Moral Reasoning during Medical Education: Combined Design Study to Evaluate the Effect of Clinical Study Years

PubMed Central

Hren, Darko; Marušić, Matko; Marušić, Ana

2011-01-01

Background Moral reasoning is important for developing medical professionalism but current evidence for the relationship between education and moral reasoning does not clearly apply to medical students. We used a combined study design to test the effect of clinical teaching on moral reasoning. Methods We used the Defining Issues Test-2 as a measure of moral judgment, with 3 general moral schemas: Personal Interest, Maintaining Norms, and Postconventional Schema. The test was applied to 3 consecutive cohorts of second year students in 2002 (n = 207), 2003 (n = 192), and 2004 (n = 139), and to 707 students of all 6 study years in 2004 cross-sectional study. We also tested 298 age-matched controls without university education. Results In the cross-sectional study, there was significant main effect of the study year for Postconventional (F(5,679) = 3.67, P = 0.003) and Personal Interest scores (F(5,679) = 3.38, P = 0.005). There was no effect of the study year for Maintaining Norms scores. 3rd year medical students scored higher on Postconventional schema score than all other study years (p<0.001). There were no statistically significant differences among 3 cohorts of 2nd year medical students, demonstrating the absence of cohort or point-of-measurement effects. Longitudinal study of 3 cohorts demonstrated that students regressed from Postconventional to Maintaining Norms schema-based reasoning after entering the clinical part of the curriculum. Interpretation Our study demonstrated direct causative relationship between the regression in moral reasoning development and clinical teaching during medical curriculum. The reasons may include hierarchical organization of clinical practice, specific nature of moral dilemmas faced by medical students, and hidden medical curriculum. PMID:21479204

A Serious Game for Teaching Nursing Students Clinical Reasoning and Decision-Making Skills.

PubMed

Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild

2016-01-01

The aim of this study was to design and pilot-test a serious game for teaching nursing students clinical reasoning and decision-making skills in caring for patients with chronic obstructive pulmonary disease. A video-based serious game prototype was developed. A purposeful sample of six participants tested and evaluated the prototype. Usability issues were identified regarding functionality and user-computer interface. However, overall the serious game was perceived to be useful, usable and likable to use.

Combining bimodal presentation schemes and buzz groups improves clinical reasoning and learning at morning report.

PubMed

Balslev, Thomas; Rasmussen, Astrid Bruun; Skajaa, Torjus; Nielsen, Jens Peter; Muijtjens, Arno; De Grave, Willem; Van Merriënboer, Jeroen

2014-12-11

Abstract Morning reports offer opportunities for intensive work-based learning. In this controlled study, we measured learning processes and outcomes with the report of paediatric emergency room patients. Twelve specialists and 12 residents were randomised into four groups and discussed the same two paediatric cases. The groups differed in their presentation modality (verbal only vs. verbal + text) and the use of buzz groups (with vs. without). The verbal interactions were analysed for clinical reasoning processes. Perceptions of learning and judgment of learning were reported in a questionnaire. Diagnostic accuracy was assessed by a 20-item multiple-choice test. Combined bimodal presentation and buzz groups increased the odds ratio of clinical reasoning to occur in the discussion of cases by a factor of 1.90 (p = 0.013), indicating superior reasoning for buzz groups working with bimodal materials. For specialists, a positive effect of bimodal presentation was found on perceptions of learning (p < 0.05), and for residents, a positive effect of buzz groups was found on judgment of learning (p < 0.005). A positive effect of bimodal presentation on diagnostic accuracy was noted in the specialists (p < 0.05). Combined bimodal presentation and buzz group discussion of emergency cases improves clinicians' clinical reasoning and learning.

[Clinical reasoning in nursing, concept analysis].

PubMed

Côté, Sarah; St-Cyr Tribble, Denise

2012-12-01

Nurses work in situations of complex care requiring great clinical reasoning abilities. In literature, clinical reasoning is often confused with other concepts and it has no consensual definition. To conduct a concept analysis of a nurse's clinical reasoning in order to clarify, define and distinguish it from the other concepts as well as to better understand clinical reasoning. Rodgers's method of concept analysis was used, after literature was retrieved with the use of clinical reasoning, concept analysis, nurse, intensive care and decision making as key-words. The use of cognition, cognitive strategies, a systematic approach of analysis and data interpretation, generating hypothesis and alternatives are attributes of clinical reasoning. The antecedents are experience, knowledge, memory, cues, intuition and data collection. The consequences are decision making, action, clues and problem resolution. This concept analysis helped to define clinical reasoning, to distinguish it from other concepts used synonymously and to guide future research.

Establishing the competences of clinical reasoning for nursing students in Taiwan: From the nurse educators' perspectives.

PubMed

Huang, Hui-Man; Huang, Chu-Yu; Lee-Hsieh, Jane; Cheng, Su-Fen

2018-07-01

Clinical reasoning is an essential core competence for nurses. Maintaining quality of care and safety of patients results from cultivation of student's clinical reasoning competency. However, the concept of clinical reasoning in nursing students is complex and its meaning and process needs further clarification. The objectives were to explore the meaning of clinical reasoning competency in Taiwanese nursing students and to operationalize the concept in order to structure a framework illustrating the process of clinical reasoning. Thirteen seasoned nursing experts who had more than ten years of experience in nursing education or clinical practice participated in the interviews. The interviews were conducted in settings that the participants perceived as convenient, quiet and free of disturbance. Semi-structured interviews were conducted. The interviews were audio-recorded and field notes were taken. The data were analyzed using Waltz et al.'s (2010) method of content analysis. The data revealed four domains and 11 competency indicators. The four domains include: awareness of clinical cues, confirmation of clinical problems, determination and implementation of actions, and evaluation and self-reflection. Each domain comprises of 2-4 indicators of clinical reasoning competency. In addition, this study established a framework for cultivation of clinical reasoning competency in nursing students. The indicators of clinical reasoning competency in nursing students are interwoven, interactive and interdependent to form a dynamic process. The findings of this study may facilitate evaluation of nursing students' clinical reasoning competency and development of instruments to assess clinical reasoning in nursing students. Copyright © 2018 Elsevier Ltd. All rights reserved.

Illness script development in pre-clinical education through case-based clinical reasoning training

PubMed Central

Keemink, Yvette; van Dijk, Savannah; ten Cate, Olle

2018-01-01

Objectives To assess illness script richness and maturity in preclinical students after they attended a specifically structured instructional format, i.e., a case based clinical reasoning (CBCR) course. Methods In a within-subject experimental design, medical students who had finished the CBCR course participated in an illness script experiment. In the first session, richness and maturity of students’ illness scripts for diseases discussed during the CBCR course were compared to illness script richness and maturity for similar diseases not included in the course. In the second session, diagnostic performance was tested, to test for differences between CBCR cases and non-CBCR cases. Scores on the CBCR course exam were related to both experimental outcomes. Results Thirty-two medical students participated. Illness script richness for CBCR diseases was almost 20% higher than for non-CBCR diseases, on average 14.47 (SD=3.25) versus 12.14 (SD=2.80), respectively (p<0.001). In addition, students provided more information on Enabling Conditions and less on Fault-related aspects of the disease. Diagnostic performance was better for the diseases discussed in the CBCR course, mean score 1.63 (SD=0.32) versus 1.15 (SD=0.29) for non-CBCR diseases (p<0.001). A significant correlation of exam results with recognition of CBCR cases was found (r=0.571, p<0.001), but not with illness script richness (r=–0.006, p=NS). Conclusions The CBCR-course fosters early development of clinical reasoning skills by increasing the illness script richness and diagnostic performance of pre-clinical students. However, these results are disease-specific and therefore we cannot conclude that students develop a more general clinical reasoning ability. PMID:29428911

Illness script development in pre-clinical education through case-based clinical reasoning training.

PubMed

Keemink, Yvette; Custers, Eugene J F M; van Dijk, Savannah; Ten Cate, Olle

2018-02-09

To assess illness script richness and maturity in preclinical students after they attended a specifically structured instructional format, i.e., a case based clinical reasoning (CBCR) course. In a within-subject experimental design, medical students who had finished the CBCR course participated in an illness script experiment. In the first session, richness and maturity of students' illness scripts for diseases discussed during the CBCR course were compared to illness script richness and maturity for similar diseases not included in the course. In the second session, diagnostic performance was tested, to test for differences between CBCR cases and non-CBCR cases. Scores on the CBCR course exam were related to both experimental outcomes. Thirty-two medical students participated. Illness script richness for CBCR diseases was almost 20% higher than for non-CBCR diseases, on average 14.47 (SD=3.25) versus 12.14 (SD=2.80), respectively (p<0.001). In addition, students provided more information on Enabling Conditions and less on Fault-related aspects of the disease. Diagnostic performance was better for the diseases discussed in the CBCR course, mean score 1.63 (SD=0.32) versus 1.15 (SD=0.29) for non-CBCR diseases (p<0.001). A significant correlation of exam results with recognition of CBCR cases was found (r=0.571, p<0.001), but not with illness script richness (r=-0.006, p=NS). The CBCR-course fosters early development of clinical reasoning skills by increasing the illness script richness and diagnostic performance of pre-clinical students. However, these results are disease-specific and therefore we cannot conclude that students develop a more general clinical reasoning ability.

Ontology-based reusable clinical document template production system.

PubMed

Nam, Sejin; Lee, Sungin; Kim, James G Boram; Kim, Hong-Gee

2012-01-01

Clinical documents embody professional clinical knowledge. This paper shows an effective clinical document template (CDT) production system that uses a clinical description entity (CDE) model, a CDE ontology, and a knowledge management system called STEP that manages ontology-based clinical description entities. The ontology represents CDEs and their inter-relations, and the STEP system stores and manages CDE ontology-based information regarding CDTs. The system also provides Web Services interfaces for search and reasoning over clinical entities. The system was populated with entities and relations extracted from 35 CDTs that were used in admission, discharge, and progress reports, as well as those used in nursing and operation functions. A clinical document template editor is shown that uses STEP.

Case-based clinical reasoning in feline medicine: 3: Use of heuristics and illness scripts.

PubMed

Whitehead, Martin L; Canfield, Paul J; Johnson, Robert; O'Brien, Carolyn R; Malik, Richard

2016-05-01

This is Article 3 of a three-part series on clinical reasoning that encourages practitioners to explore and understand how they think and make case-based decisions. It is hoped that, in the process, they will learn to trust their intuition but, at the same time, put in place safeguards to diminish the impact of bias and misguided logic on their diagnostic decision-making. Article 1, published in the January 2016 issue of JFMS, discussed the relative merits and shortcomings of System 1 thinking (immediate and unconscious) and System 2 thinking (effortful and analytical). In Article 2, published in the March 2016 issue, ways of managing cognitive error, particularly the negative impact of bias, in making a diagnosis were examined. This final article explores the use of heuristics (mental short cuts) and illness scripts in diagnostic reasoning. © The Author(s) 2016.

Case-based clinical reasoning in feline medicine: 2: Managing cognitive error.

PubMed

Canfield, Paul J; Whitehead, Martin L; Johnson, Robert; O'Brien, Carolyn R; Malik, Richard

2016-03-01

This is Article 2 of a three-part series on clinical reasoning that encourages practitioners to explore and understand how they think and make case-based decisions. It is hoped that, in the process, they will learn to trust their intuition but, at the same time, put in place safeguards to diminish the impact of bias and misguided logic on their diagnostic decision-making. Article 1, published in the January 2016 issue of JFMS, discussed the relative merits and shortcomings of System 1 thinking (immediate and unconscious) and System 2 thinking (effortful and analytical). This second article examines ways of managing cognitive error, particularly the negative impact of bias, when making a diagnosis. Article 3, to appear in the May 2016 issue, explores the use of heuristics (mental short cuts) and illness scripts in diagnostic reasoning. © The Author(s) 2016.

Puzzle test: A tool for non-analytical clinical reasoning assessment.

PubMed

Monajemi, Alireza; Yaghmaei, Minoo

2016-01-01

Most contemporary clinical reasoning tests typically assess non-automatic thinking. Therefore, a test is needed to measure automatic reasoning or pattern recognition, which has been largely neglected in clinical reasoning tests. The Puzzle Test (PT) is dedicated to assess automatic clinical reasoning in routine situations. This test has been introduced first in 2009 by Monajemi et al in the Olympiad for Medical Sciences Students.PT is an item format that has gained acceptance in medical education, but no detailed guidelines exist for this test's format, construction and scoring. In this article, a format is described and the steps to prepare and administer valid and reliable PTs are presented. PT examines a specific clinical reasoning task: Pattern recognition. PT does not replace other clinical reasoning assessment tools. However, it complements them in strategies for assessing comprehensive clinical reasoning.

[Clinical reasoning in undergraduate nursing education: a scoping review].

PubMed

Menezes, Sáskia Sampaio Cipriano de; Corrêa, Consuelo Garcia; Silva, Rita de Cássia Gengo E; Cruz, Diná de Almeida Monteiro Lopes da

2015-12-01

This study aimed at analyzing the current state of knowledge on clinical reasoning in undergraduate nursing education. A systematic scoping review through a search strategy applied to the MEDLINE database, and an analysis of the material recovered by extracting data done by two independent reviewers. The extracted data were analyzed and synthesized in a narrative manner. From the 1380 citations retrieved in the search, 23 were kept for review and their contents were summarized into five categories: 1) the experience of developing critical thinking/clinical reasoning/decision-making process; 2) teaching strategies related to the development of critical thinking/clinical reasoning/decision-making process; 3) measurement of variables related to the critical thinking/clinical reasoning/decision-making process; 4) relationship of variables involved in the critical thinking/clinical reasoning/decision-making process; and 5) theoretical development models of critical thinking/clinical reasoning/decision-making process for students. The biggest challenge for developing knowledge on teaching clinical reasoning seems to be finding consistency between theoretical perspectives on the development of clinical reasoning and methodologies, methods, and procedures in research initiatives in this field.

Promoting student case creation to enhance instruction of clinical reasoning skills: a pilot feasibility study.

PubMed

Chandrasekar, Hamsika; Gesundheit, Neil; Nevins, Andrew B; Pompei, Peter; Bruce, Janine; Merrell, Sylvia Bereknyei

2018-01-01

It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student-faculty interaction. Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions. Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student-faculty interaction and the use of visual aids ( P < 0.05). The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student-faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills.

Promoting student case creation to enhance instruction of clinical reasoning skills: a pilot feasibility study

PubMed Central

Chandrasekar, Hamsika; Gesundheit, Neil; Nevins, Andrew B; Pompei, Peter; Bruce, Janine; Merrell, Sylvia Bereknyei

2018-01-01

Background It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student–faculty interaction. Methods Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions. Results Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student–faculty interaction and the use of visual aids (P < 0.05). Conclusion The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student–faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills. PMID:29692641

Using Relational Reasoning Strategies to Help Improve Clinical Reasoning Practice.

PubMed

Dumas, Denis; Torre, Dario M; Durning, Steven J

2018-05-01

Clinical reasoning-the steps up to and including establishing a diagnosis and/or therapy-is a fundamentally important mental process for physicians. Unfortunately, mounting evidence suggests that errors in clinical reasoning lead to substantial problems for medical professionals and patients alike, including suboptimal care, malpractice claims, and rising health care costs. For this reason, cognitive strategies by which clinical reasoning may be improved-and that many expert clinicians are already using-are highly relevant for all medical professionals, educators, and learners.In this Perspective, the authors introduce one group of cognitive strategies-termed relational reasoning strategies-that have been empirically shown, through limited educational and psychological research, to improve the accuracy of learners' reasoning both within and outside of the medical disciplines. The authors contend that relational reasoning strategies may help clinicians to be metacognitive about their own clinical reasoning; such strategies may also be particularly well suited for explicitly organizing clinical reasoning instruction for learners. Because the particular curricular efforts that may improve the relational reasoning of medical students are not known at this point, the authors describe the nature of previous research on relational reasoning strategies to encourage the future design, implementation, and evaluation of instructional interventions for relational reasoning within the medical education literature. The authors also call for continued research on using relational reasoning strategies and their role in clinical practice and medical education, with the long-term goal of improving diagnostic accuracy.

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

PubMed

Fischer, Markus A; Kennedy, Kieran M; Durning, Steven; Schijven, Marlies P; Ker, Jean; O'Connor, Paul; Doherty, Eva; Kropmans, Thomas J B

2017-12-21

Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study.

PubMed

Poll, Ray; Allmark, Peter; Tod, Angela M

2017-01-01

Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem. Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The 'framework method' was used to analyse the data with key themes identified. Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave 'prima-facie' reasons for non-attendance including 'not a priority' and 'forgot'. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. 'priority' to score drugs and the 'cost of travel' and (ii) clinic service e.g. 'difficult journey' to the clinic and timing of the 'appointment'. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself. The study revealed that beneath apparently simple explanations for non-attendance, such as clients' chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients' perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective. Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.

Integrating clinical communication with clinical reasoning and the broader medical curriculum.

PubMed

Cary, Julie; Kurtz, Suzanne

2013-09-01

The objectives of this paper are to discuss the results of a workshop conducted at EACH 2012. Specifically, we will (1) examine the link between communication, clinical reasoning, and medical problem solving, (2) explore strategies for (a) integrating clinical reasoning, medical problem solving, and content from the broader curriculum into clinical communication teaching and (b) integrating communication into the broader curriculum, and (3) discuss benefits gained from such integration. Salient features from the workshop were recorded and will be presented here, as well as a case example to illustrate important connections between clinical communication and clinical reasoning. Potential links between clinical communication, clinical reasoning, and medical problem solving as well as strategies to integrate clinical communication teaching and the broader curricula in human and veterinary medicine are enumerated. Participants expressed enthusiasm and keen interest in integration of clinical communication teaching and clinical reasoning during this workshop, came to the idea of the interdependence of these skills easily, and embraced the rationale immediately. Valuing the importance of communication as clinical skill and embracing the interdependence between communication and thought processes related to clinical reasoning and medical problem solving will be beneficial in teaching programs. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Educational strategies for improving clinical reasoning.

PubMed

Cutrer, William B; Sullivan, William M; Fleming, Amy E

2013-10-01

Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learner's reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities. © 2013 Mosby, Inc. All rights reserved.

Learning by playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical reasoning.

PubMed

Koivisto, Jaana-Maija; Multisilta, Jari; Niemi, Hannele; Katajisto, Jouko; Eriksson, Elina

2016-10-01

Clinical reasoning is viewed as a problem-solving activity; in games, players solve problems. To provide excellent patient care, nursing students must gain competence in clinical reasoning. Utilising gaming elements and virtual simulations may enhance learning of clinical reasoning. To investigate nursing students' experiences of learning clinical reasoning process by playing a 3D simulation game. Cross-sectional descriptive study. Thirteen gaming sessions at two universities of applied sciences in Finland. The prototype of the simulation game used in this study was single-player in format. The game mechanics were built around the clinical reasoning process. Nursing students from the surgical nursing course of autumn 2014 (N=166). Data were collected by means of an online questionnaire. In terms of the clinical reasoning process, students learned how to take action and collect information but were less successful in learning to establish goals for patient care or to evaluate the effectiveness of interventions. Learning of the different phases of clinical reasoning process was strongly positively correlated. The students described that they learned mainly to apply theoretical knowledge while playing. The results show that those who played digital games daily or occasionally felt that they learned clinical reasoning by playing the game more than those who did not play at all. Nursing students' experiences of learning the clinical reasoning process by playing a 3D simulation game showed that such games can be used successfully for learning. To ensure that students follow a systematic approach, the game mechanics need to be built around the clinical reasoning process. Copyright © 2016 Elsevier Ltd. All rights reserved.

"...because I am something special" or "I think I will be something like a guinea pig": information and assent of legal minors in clinical trials – assessment of understanding, appreciation and reasoning

PubMed Central

Koelch, Michael; Singer, Hanneke; Prestel, Anja; Burkert, Jessica; Schulze, Ulrike; Fegert, Jörg M

2009-01-01

Background The aim of this study is to assess and evaluate the capacities for understanding, appreciation and reasoning of legal minors with psychiatric disorders and their parents and their competence to consent or assent to participation in clinical trials. The beliefs, fears, motivation and influencing factors for decision-making of legal minors and parents were also examined. Methods Using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), an instrument developed for adults whose capacities to consent are unclear, we provided information about clinical trials and assessed understanding, appreciation and reasoning. We adapted this tool for legal minors and examined 19 children and adolescents between the ages of 7 and 15 with attention deficit/hyperactivity disorder (ADHD) or ADHD combined with oppositional defiant disorder (DSM-IV 314.00/314.01/312.8) enrolled in clinical trials. Parents were also examined using the MacCAT-CR. Results Facts such as the procedures involved in trials or their duration were well understood by legal minors, but more abstract issues like the primary purpose of the trial were not understood by children and adolescents or by many parents. Legal minors also had difficulties understanding the nature of placebo and the probability of receiving placebo. Children's and adolescents' decisions were influenced by fears about their disorder worsening and by problems in their relationship with their parents. Parents wanted the best therapy for their children in order to minimize problems in school. Conclusion Legal minors and parents need to be informed more precisely about specific issues like placebo and the primary purpose of trials. In general, the reasoning of children and adolescents was influenced by their experience with their disorder and decision making was based on reasonable arguments. Their fears were based on everyday experiences such as school performance or family relationships. PMID:19175905

Psychometric characteristics of Clinical Reasoning Problems (CRPs) and its correlation with routine multiple choice question (MCQ) in Cardiology department.

PubMed

Derakhshandeh, Zahra; Amini, Mitra; Kojuri, Javad; Dehbozorgian, Marziyeh

2018-01-01

Clinical reasoning is one of the most important skills in the process of training a medical student to become an efficient physician. Assessment of the reasoning skills in a medical school program is important to direct students' learning. One of the tests for measuring the clinical reasoning ability is Clinical Reasoning Problems (CRPs). The major aim of this study is to measure psychometric qualities of CRPs and define correlation between this test and routine MCQ in cardiology department of Shiraz medical school. This study was a descriptive study conducted on total cardiology residents of Shiraz Medical School. The study population consists of 40 residents in 2014. The routine CRPs and the MCQ tests was designed based on similar objectives and were carried out simultaneously. Reliability, item difficulty, item discrimination, and correlation between each item and the total score of CRPs were all measured by Excel and SPSS software for checking psycometeric CRPs test. Furthermore, we calculated the correlation between CRPs test and MCQ test. The mean differences of CRPs test score between residents' academic year [second, third and fourth year] were also evaluated by Analysis of variances test (One Way ANOVA) using SPSS software (version 20)(α=0.05). The mean and standard deviation of score in CRPs was 10.19 ±3.39 out of 20; in MCQ, it was 13.15±3.81 out of 20. Item difficulty was in the range of 0.27-0.72; item discrimination was 0.30-0.75 with question No.3 being the exception (that was 0.24). The correlation between each item and the total score of CRP was 0.26-0.87; the correlation between CRPs test and MCQ test was 0.68 (p<0.001). The reliability of the CRPs was 0.72 as calculated by using Cronbach's alpha. The mean score of CRPs was different among residents based on their academic year and this difference was statistically significant (p<0.001). The results of this present investigation revealed that CRPs could be reliable test for measuring clinical reasoning in residents. It can be included in cardiology residency assessment programs.

Connecting Classroom, Clinic, and Context: Clinical Reasoning Strategies for Clinical Instructors and Academic Faculty.

PubMed

Furze, Jennifer; Kenyon, Lisa K; Jensen, Gail M

2015-01-01

Clinical reasoning is an essential skill in pediatric physical therapist (PT) practice. As such, explicit instruction in clinical reasoning should be emphasized in PT education. This article provides academic faculty and clinical instructors with an overview of strategies to develop and expand the clinical reasoning capacity of PT students within the scope of pediatric PT practice. Achieving a balance between deductive reasoning strategies that provide a framework for thinking and inductive reasoning strategies that emphasize patient factors and the context of the clinical situation is an important variable in educational pedagogy. Consideration should be given to implementing various teaching and learning approaches across the curriculum that reflect the developmental level of the student(s). Deductive strategies may be helpful early in the curriculum, whereas inductive strategies are often advantageous after patient interactions; however, exposure to both is necessary to fully develop the learner's clinical reasoning abilities. For more insights from the authors, see Supplemental Digital Content 1, available at http://links.lww.com/PPT/A87.

Feasibility and Acceptability of Smartphone Assessment in Older Adults with Cognitive and Emotional Difficulties

PubMed Central

Ramsey, Alex T.; Wetherell, Julie Loebach; Depp, Colin; Dixon, David; Lenze, Eric

2016-01-01

Objectives Ecological momentary assessment (EMA) has several advantages in clinical research yet little is known about the feasibility of collecting EMA data with mobile technologies in older adults, particularly those with emotional or cognitive difficulties. The aim of this feasibility study was to assess perceived acceptability, adherence rates, and reasons for non-adherence to smartphone-based EMA. Method At two sites, participants (n=103) aged 65 years or older with a DSM-IV-defined anxiety or depressive disorder and cognitive concerns responded three times daily to smartphone-based EMA questions assessing clinical outcomes for two 10-day periods. Quantitative and qualitative measures assessed acceptability, adherence, and reasons for non-adherence following both 10-day EMA periods. Results Participants were moderately satisfied with and comfortable using smartphone-based EMA. Overall, 76% of participants completed surveys on ≥10 of the 20 assessment days, and 70% of participants completed at least 30% of the total surveys. Reasons for non-adherence included technical (malfunction), logistical (competing demands), physiological (hearing difficulties), and cognitive (forgetting) issues. Discussion Smartphone-based EMA is feasible in older adults with cognitive and emotional difficulties. EMA tools should be responsive to the needs and preferences of participants to ensure adequate acceptability and adherence in this population. Our findings can inform the design, development, and implementation of mobile technologies in older adults in research and clinical contexts. PMID:27683018

Feasibility and Acceptability of Smartphone Assessment in Older Adults with Cognitive and Emotional Difficulties.

PubMed

Ramsey, Alex T; Wetherell, Julie Loebach; Depp, Colin; Dixon, David; Lenze, Eric

Ecological momentary assessment (EMA) has several advantages in clinical research yet little is known about the feasibility of collecting EMA data with mobile technologies in older adults, particularly those with emotional or cognitive difficulties. The aim of this feasibility study was to assess perceived acceptability, adherence rates, and reasons for non-adherence to smartphone-based EMA. At two sites, participants ( n =103) aged 65 years or older with a DSM-IV-defined anxiety or depressive disorder and cognitive concerns responded three times daily to smartphone-based EMA questions assessing clinical outcomes for two 10-day periods. Quantitative and qualitative measures assessed acceptability, adherence, and reasons for non-adherence following both 10-day EMA periods. Participants were moderately satisfied with and comfortable using smartphone-based EMA. Overall, 76% of participants completed surveys on ≥10 of the 20 assessment days, and 70% of participants completed at least 30% of the total surveys. Reasons for non-adherence included technical (malfunction), logistical (competing demands), physiological (hearing difficulties), and cognitive (forgetting) issues. Smartphone-based EMA is feasible in older adults with cognitive and emotional difficulties. EMA tools should be responsive to the needs and preferences of participants to ensure adequate acceptability and adherence in this population. Our findings can inform the design, development, and implementation of mobile technologies in older adults in research and clinical contexts.

iCBLS: An interactive case-based learning system for medical education.

PubMed

Ali, Maqbool; Han, Soyeon Caren; Bilal, Hafiz Syed Muhammad; Lee, Sungyoung; Kang, Matthew Jee Yun; Kang, Byeong Ho; Razzaq, Muhammad Asif; Amin, Muhammad Bilal

2018-01-01

Medical students should be able to actively apply clinical reasoning skills to further their interpretative, diagnostic, and treatment skills in a non-obtrusive and scalable way. Case-Based Learning (CBL) approach has been receiving attention in medical education as it is a student-centered teaching methodology that exposes students to real-world scenarios that need to be solved using their reasoning skills and existing theoretical knowledge. In this paper, we propose an interactive CBL System, called iCBLS, which supports the development of collaborative clinical reasoning skills for medical students in an online environment. The iCBLS consists of three modules: (i) system administration (SA), (ii) clinical case creation (CCC) with an innovative semi-automatic approach, and (iii) case formulation (CF) through intervention of medical students' and teachers' knowledge. Two evaluations under the umbrella of the context/input/process/product (CIPP) model have been performed with a Glycemia study. The first focused on the system satisfaction, evaluated by 54 students. The latter aimed to evaluate the system effectiveness, simulated by 155 students. The results show a high success rate of 70% for students' interaction, 76.4% for group learning, 72.8% for solo learning, and 74.6% for improved clinical skills. Copyright © 2017 Elsevier B.V. All rights reserved.

Construction of a Clinical Decision Support System for Undergoing Surgery Based on Domain Ontology and Rules Reasoning

PubMed Central

Bau, Cho-Tsan; Huang, Chung-Yi

2014-01-01

Abstract Objective: To construct a clinical decision support system (CDSS) for undergoing surgery based on domain ontology and rules reasoning in the setting of hospitalized diabetic patients. Materials and Methods: The ontology was created with a modified ontology development method, including specification and conceptualization, formalization, implementation, and evaluation and maintenance. The Protégé–Web Ontology Language editor was used to implement the ontology. Embedded clinical knowledge was elicited to complement the domain ontology with formal concept analysis. The decision rules were translated into JENA format, which JENA can use to infer recommendations based on patient clinical situations. Results: The ontology includes 31 classes and 13 properties, plus 38 JENA rules that were built to generate recommendations. The evaluation studies confirmed the correctness of the ontology, acceptance of recommendations, satisfaction with the system, and usefulness of the ontology for glycemic management of diabetic patients undergoing surgery, especially for domain experts. Conclusions: The contribution of this research is to set up an evidence-based hybrid ontology and an evaluation method for CDSS. The system can help clinicians to achieve inpatient glycemic control in diabetic patients undergoing surgery while avoiding hypoglycemia. PMID:24730353

Construction of a clinical decision support system for undergoing surgery based on domain ontology and rules reasoning.

PubMed

Bau, Cho-Tsan; Chen, Rung-Ching; Huang, Chung-Yi

2014-05-01

To construct a clinical decision support system (CDSS) for undergoing surgery based on domain ontology and rules reasoning in the setting of hospitalized diabetic patients. The ontology was created with a modified ontology development method, including specification and conceptualization, formalization, implementation, and evaluation and maintenance. The Protégé-Web Ontology Language editor was used to implement the ontology. Embedded clinical knowledge was elicited to complement the domain ontology with formal concept analysis. The decision rules were translated into JENA format, which JENA can use to infer recommendations based on patient clinical situations. The ontology includes 31 classes and 13 properties, plus 38 JENA rules that were built to generate recommendations. The evaluation studies confirmed the correctness of the ontology, acceptance of recommendations, satisfaction with the system, and usefulness of the ontology for glycemic management of diabetic patients undergoing surgery, especially for domain experts. The contribution of this research is to set up an evidence-based hybrid ontology and an evaluation method for CDSS. The system can help clinicians to achieve inpatient glycemic control in diabetic patients undergoing surgery while avoiding hypoglycemia.

Strengthening moral reasoning through dedicated ethics training in dietetic preparatory programs.

PubMed

Hewko, Sarah J; Cooper, Sarah L; Cummings, Greta G

2015-01-01

Moral reasoning skills, associated with the ability to make ethical decisions effectively, must be purposively fostered. Among health professionals, enhanced moral reasoning is linked to superior clinical performance. Research demonstrates that moral reasoning is enhanced through dedicated, discussion-based ethics education offered over a period of 3-12 weeks. Current dietetic students and practicing dietitians seeking to strengthen their moral reasoning skills can undertake elective ethics education. Further research within dietetic preparatory programs is warranted to better inform the development and implementation of ethics courses. Copyright © 2015 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

Reasoning by analogy requires the left frontal pole: lesion-deficit mapping and clinical implications.

PubMed

Urbanski, Marika; Bréchemier, Marie-Laure; Garcin, Béatrice; Bendetowicz, David; Thiebaut de Schotten, Michel; Foulon, Chris; Rosso, Charlotte; Clarençon, Frédéric; Dupont, Sophie; Pradat-Diehl, Pascale; Labeyrie, Marc-Antoine; Levy, Richard; Volle, Emmanuelle

2016-06-01

SEE BURGESS DOI101093/BRAIN/AWW092 FOR A SCIENTIFIC COMMENTARY ON THIS ARTICLE  : Analogical reasoning is at the core of the generalization and abstraction processes that enable concept formation and creativity. The impact of neurological diseases on analogical reasoning is poorly known, despite its importance in everyday life and in society. Neuroimaging studies of healthy subjects and the few studies that have been performed on patients have highlighted the importance of the prefrontal cortex in analogical reasoning. However, the critical cerebral bases for analogical reasoning deficits remain elusive. In the current study, we examined analogical reasoning abilities in 27 patients with focal damage in the frontal lobes and performed voxel-based lesion-behaviour mapping and tractography analyses to investigate the structures critical for analogical reasoning. The findings revealed that damage to the left rostrolateral prefrontal region (or some of its long-range connections) specifically impaired the ability to reason by analogies. A short version of the analogy task predicted the existence of a left rostrolateral prefrontal lesion with good accuracy. Experimental manipulations of the analogy tasks suggested that this region plays a role in relational matching or integration. The current lesion approach demonstrated that the left rostrolateral prefrontal region is a critical node in the analogy network. Our results also suggested that analogy tasks should be translated to clinical practice to refine the neuropsychological assessment of patients with frontal lobe lesions. © The Author (2016). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Development and validation of Dutch version of Lasater Clinical Judgment Rubric in hospital practice: An instrument design study.

PubMed

Vreugdenhil, Jettie; Spek, Bea

2018-03-01

Clinical reasoning in patient care is a skill that cannot be observed directly. So far, no reliable, valid instrument exists for the assessment of nursing students' clinical reasoning skills in hospital practice. Lasater's clinical judgment rubric (LCJR), based on Tanner's model "Thinking like a nurse" has been tested, mainly in academic simulation settings. The aim is to develop a Dutch version of the LCJR (D-LCJR) and to test its psychometric properties when used in a hospital traineeship context. A mixed-model approach was used to develop and to validate the instrument. Ten dedicated educational units in a university hospital. A well-mixed group of 52 nursing students, nurse coaches and nurse educators. A Delphi panel developed the D-LCJR. Students' clinical reasoning skills were assessed "live" by nurse coaches, nurse educators and students who rated themselves. The psychometric properties tested during the assessment process are reliability, reproducibility, content validity and construct validity by testing two hypothesis: 1) a positive correlation between assessed and self-reported sum scores (convergent validity) and 2) a linear relation between experience and sum score (clinical validity). The obtained D-LCJR was found to be internally consistent, Cronbach's alpha 0.93. The rubric is also reproducible with intraclass correlations between 0.69 and 0.78. Experts judged it to be content valid. The two hypothesis were both tested significant, supporting evidence for construct validity. The translated and modified LCJR, is a promising tool for the evaluation of nursing students' development in clinical reasoning in hospital traineeships, by students, nurse coaches and nurse educators. More evidence on construct validity is necessary, in particular for students at the end of their hospital traineeship. Based on our research, the D-LCJR applied in hospital traineeships is a usable and reliable tool. Copyright © 2017 Elsevier Ltd. All rights reserved.

Novel examination for evaluating medical student clinical reasoning: reliability and association with patients seen.

PubMed

Hemmer, Paul A; Dong, Ting; Durning, Steven J; Pangaro, Louis N

2015-04-01

Medical students learn clinical reasoning, in part, through patient care. Although the numbers of patients seen is associated with knowledge examination scores, studies have not demonstrated an association between patient problems and an assessment of clinical reasoning. To examine the reliability of a clinical reasoning examination and investigate whether there was association between internal medicine core clerkship students' performance on this examination and the number of patients they saw with matching problems during their internal medicine clerkship. Students on the core internal medicine clerkship at the Uniformed Services University students log 11 core patient problems based on the Clerkship Directors in Internal Medicine curriculum. On a final clerkship examination (Multistep), students watch a scripted video encounter between physician and patient actors that assesses three sequential steps in clinical reasoning: Step One focuses on history and physical examination; Step Two, students write a problem list after viewing additional clinical findings; Step Three, students complete a prioritized differential diagnosis and treatment plan. Each Multistep examination has three different cases. For graduating classes 2010-2012 (n = 497), we matched the number of patients seen with the problem most represented by the Multistep cases (epigastric pain, generalized edema, monoarticular arthritis, angina, syncope, pleuritic chest pain). We report two-way Pearson correlations between the number of patients students reported with similar problems and the student's percent score on: Step One, Step Two, Step Three, and Overall Test. Multistep reliability: Step 1, 0.6 to 0.8; Step 2, 0.41 to 0.65; Step 3, 0.53 to 0.78; Overall examination (3 cases): 0.74 to 0.83. For three problems, the number of patients seen had small to modest correlations with the Multistep Examination of Analytic Ability total score (r = 0.27 for pleuritic pain, p < 0.05, n = 81 patients; r = 0.14 for epigastric pain, p < 0.05, n = 324 patients; r = 0.19 for generalized edema, p < 0.05, n = 118 patients). DISCUSSION or Although a reliable assessment, student performance on a clinical reasoning examination was weakly associated with the numbers of patients seen with similar problems. This may be as a result of transfer of knowledge between clinical and examination settings, the complexity of clinical reasoning, or the limits of reliability with patient logs and the Multistep. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

The role of electronic health records in clinical reasoning.

PubMed

Berndt, Markus; Fischer, Martin R

2018-05-16

Electronic health records (eHRs) play an increasingly important role in documentation and exchange of information in multi-and interdisciplinary patient care. Although eHRs are associated with mixed evidence in terms of effectiveness, they are undeniably the health record form of the future. This poses several learning opportunities and challenges for medical education. This review aims to connect the concept of eHRs to key competencies of physicians and elaborates current learning science perspectives on diagnostic and clinical reasoning based on a theoretical framework of scientific reasoning and argumentation. It concludes with an integrative vision of the use of eHRs, and the special role of the patient, for teaching and learning in medicine. © 2018 New York Academy of Sciences.

A Functional Neuroimaging Study of the Clinical Reasoning of Medical Students

ERIC Educational Resources Information Center

Chang, Hyung-Joo; Kang, June; Ham, Byung-Joo; Lee, Young-Mee

2016-01-01

As clinical reasoning is a fundamental competence of physicians for good clinical practices, medical academics have endeavored to teach reasoning skills to undergraduate students. However, our current understanding of student-level clinical reasoning is limited, mainly because of the lack of evaluation tools for this internal cognitive process.…

"Perpetual Problem-Solving": An Ethnographic Study of Clinical Reasoning in a Therapeutic Recreation Setting.

ERIC Educational Resources Information Center

Hutchinson, Susan L.; LeBlanc, Adrienne; Booth, Rhonda

2002-01-01

Reviews literature on the concept and practice of clinical reasoning, presenting evidence of clinical reasoning in a therapeutic recreation setting. Data from observations of and interviews with recreation therapists and clients in a Canadian rehabilitation hospital provided evidence of therapists' clinical reasoning practices which supported the…

Case-Based Analogical Reasoning: A Pedagogical Tool for Promotion of Clinical Reasoning

ERIC Educational Resources Information Center

Speicher, Timothy E.; Bell, Alexandra; Kehrhahn, Marijke; Casa, Douglas J.

2012-01-01

Context: One of the most common instructional methods utilized to promote learning transfer in health profession education is examination of a single patient case. However, in non-healthcare settings this practice has shown to be less effective in promoting learning than the examination of multiple cases with cueing. Objective(s): The primary…

Teaching Skills to Promote Clinical Reasoning in Early Basic Science Courses

ERIC Educational Resources Information Center

Elizondo-Omana, Rodrigo Enrique; Morales-Gomez, Jesus Alberto; Morquecho-Espinoza, Orlando; Hinojosa-Amaya, Jose Miguel; Villarreal-Silva, Eliud Enrique; Garcia-Rodriguez, Maria de los Angeles; Guzman-Lopez, Santos

2010-01-01

Basic and superior reasoning skills are woven into the clinical reasoning process just as they are used to solve any problem. As clinical reasoning is the central competence of medical education, development of these reasoning skills should occur throughout the undergraduate medical curriculum. The authors describe here a method of teaching…

Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.

PubMed

Young, Meredith; Thomas, Aliki; Lubarsky, Stuart; Ballard, Tiffany; Gordon, David; Gruppen, Larry D; Holmboe, Eric; Ratcliffe, Temple; Rencic, Joe; Schuwirth, Lambert; Durning, Steven J

2018-01-23

Clinical reasoning is an essential component of a health professional's practice. Yet clinical reasoning research has produced a notably fragmented body of literature. In this article, the authors describe the pause-and-reflect exercise they undertook during the execution of a synthesis of the literature on clinical reasoning in the health professions. Confronted with the challenge of establishing a shared understanding of the nature and relevant components of clinical reasoning, members of the review team paused to independently generate their own personal definitions and conceptualizations of the construct. Here, the authors describe the variability of definitions and conceptualizations of clinical reasoning present within their own team. Drawing on an analogy from mathematics, they hypothesize that the presence of differing "boundary conditions" could help explain individuals' differing conceptualizations of clinical reasoning and the fragmentation at play in the wider sphere of research on clinical reasoning. Specifically, boundary conditions refer to the practice of describing the conditions under which a given theory is expected to hold, or expected to have explanatory power. Given multiple theoretical frameworks, research methodologies, and assessment approaches contained within the clinical reasoning literature, different boundary conditions are likely at play. Open acknowledgment of different boundary conditions and explicit description of the conceptualization of clinical reasoning being adopted within a given study would improve research communication, support comprehensive approaches to teaching and assessing clinical reasoning, and perhaps encourage new collaborative partnerships among researchers who adopt different boundary conditions.Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

Subject preferences of first- and second-year medical students for their future specialization at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal - a questionnaire-based study.

PubMed

Jha, Rajesh K; Paudel, Keshab R; Shah, Dev K; Sah, Ajit K; Basnet, Sangharshila; Sah, Phoolgen; Adhikari, Sandeep

2015-01-01

The selection of a discipline for future specialization may be an important factor for the medical students' future career, and it is influenced by multiple factors. The interest of students in the early stages can be improved in subjects related to public health or of academic importance, as per need. A questionnaire-based study was conducted among 265 first- and second-year medical students of Chitwan Medical College, Nepal to find out their subject of preference for postgraduation and the factors affecting their selection along with their interesting basic science subject. Only the responses from 232 completely filled questionnaires were analyzed. The preference of the students for clinical surgical (50.9%), clinical medical (45.3%), and basic medical (3.9%) sciences for postgraduation were in descending order. The most preferred specialty among male students was clinical surgical sciences (56.3%), and among female students, it was clinical medical sciences (53.6%). Although all the students responded to their preferred specialty, only 178 students specified the subject of their interest. General surgery (23.4%), pediatrics (23.4%), and anatomy (2.4%) were the most favored subjects for postgraduation among clinical surgical, clinical medical, and basic medical sciences specialties, respectively. More common reasons for selection of specific subject for future career were found to be: personal interests, good income, intellectual challenge, and others. Many students preferred clinical surgical sciences for their future specialization. Among the reasons for the selection of the specialty for postgraduation, no significant reason could be elicited from the present study.

Development and implementation of a clinical needs assessment to support nursing and midwifery students with a disability in clinical practice: part 1.

PubMed

Howlin, Frances; Halligan, Phil; O'Toole, Sinead

2014-09-01

Equality and disability legislation, coupled with increasing numbers of students with a disability, and inadequate supports in clinical practice, acted as catalysts to explore how best to support undergraduate nursing and midwifery students on clinical placements. Historically, higher education institutions provide reasonable accommodations for theoretical rather than clinical modules for practice placements. This paper describes the development and implementation of a Clinical Needs Assessment designed to identify the necessary supports or reasonable accommodations for nursing and midwifery students with a disability undertaking work placements in clinical practice. The existing literature, and consultation with an expert panel, revealed that needs assessments should be competency based and clearly identify the core skills or elements of practice that the student must attain to achieve proficiency and competence. The five Domains of Competence, advocated by An Bord Altranais, the Nursing and Midwifery Board of Ireland, formed the framework for the Clinical Needs Assessment. A panel of experts generated performance indicators to enable the identification of individualised reasonable accommodations for year 1 nursing and midwifery students in one Irish University. Development and implementation of the Clinical Needs Assessment promoted equality, inclusion and a level playing field for nursing and midwifery students with a disability in clinical practice. Copyright © 2014 Elsevier Ltd. All rights reserved.

Inverse reasoning processes in obsessive-compulsive disorder.

PubMed

Wong, Shiu F; Grisham, Jessica R

2017-04-01

The inference-based approach (IBA) is one cognitive model that aims to explain the aetiology and maintenance of obsessive-compulsive disorder (OCD). The model proposes that certain reasoning processes lead an individual with OCD to confuse an imagined possibility with an actual probability, a state termed inferential confusion. One such reasoning process is inverse reasoning, in which hypothetical causes form the basis of conclusions about reality. Although previous research has found associations between a self-report measure of inferential confusion and OCD symptoms, evidence of a specific association between inverse reasoning and OCD symptoms is lacking. In the present study, we developed a task-based measure of inverse reasoning in order to investigate whether performance on this task is associated with OCD symptoms in an online sample. The results provide some evidence for the IBA assertion: greater endorsement of inverse reasoning was significantly associated with OCD symptoms, even when controlling for general distress and OCD-related beliefs. Future research is needed to replicate this result in a clinical sample and to investigate a potential causal role for inverse reasoning in OCD. Copyright © 2016 Elsevier Ltd. All rights reserved.

Case-Based Web Learning Versus Face-to-Face Learning: A Mixed-Method Study on University Nursing Students.

PubMed

Chan, Aileen Wai-Kiu; Chair, Sek-Ying; Sit, Janet Wing-Hung; Wong, Eliza Mi-Ling; Lee, Diana Tze-Fun; Fung, Olivia Wai-Man

2016-03-01

Case-based learning (CBL) is an effective educational method for improving the learning and clinical reasoning skills of students. Advances in e-learning technology have supported the development of the Web-based CBL approach to teaching as an alternative or supplement to the traditional classroom approach. This study aims to examine the CBL experience of Hong Kong students using both traditional classroom and Web-based approaches in undergraduate nursing education. This experience is examined in terms of the perceived self-learning ability, clinical reasoning ability, and satisfaction in learning of these students. A mixture of quantitative and qualitative approaches was adopted. All Year-3 undergraduate nursing students were recruited. CBL was conducted using the traditional classroom approach in Semester 1, and the Web-based approach was conducted in Semester 2. Student evaluations were collected at the end of each semester using a self-report questionnaire. In-depth, focus-group interviews were conducted at the end of Semester 2. One hundred twenty-two students returned their questionnaires. No difference between the face-to-face and Web-based approaches was found in terms of self-learning ability (p = .947), clinical reasoning ability (p = .721), and satisfaction (p = .083). Focus group interview findings complemented survey findings and revealed five themes that reflected the CBL learning experience of Hong Kong students. These themes were (a) the structure of CBL, (b) the learning environment of Web-based CBL, (c) critical thinking and problem solving, (d) cultural influence on CBL learning experience, and (e) student-centered and teacher-centered learning. The Web-based CBL approach was comparable but not superior to the traditional classroom CBL approach. The Web-based CBL experience of these students sheds light on the impact of Chinese culture on student learning behavior and preferences.

A platform for exploration into chaining of web services for clinical data transformation and reasoning.

PubMed

Maldonado, José Alberto; Marcos, Mar; Fernández-Breis, Jesualdo Tomás; Parcero, Estíbaliz; Boscá, Diego; Legaz-García, María Del Carmen; Martínez-Salvador, Begoña; Robles, Montserrat

2016-01-01

The heterogeneity of clinical data is a key problem in the sharing and reuse of Electronic Health Record (EHR) data. We approach this problem through the combined use of EHR standards and semantic web technologies, concretely by means of clinical data transformation applications that convert EHR data in proprietary format, first into clinical information models based on archetypes, and then into RDF/OWL extracts which can be used for automated reasoning. In this paper we describe a proof-of-concept platform to facilitate the (re)configuration of such clinical data transformation applications. The platform is built upon a number of web services dealing with transformations at different levels (such as normalization or abstraction), and relies on a collection of reusable mappings designed to solve specific transformation steps in a particular clinical domain. The platform has been used in the development of two different data transformation applications in the area of colorectal cancer.

Inductive and deductive reasoning in obsessive-compulsive disorder.

PubMed

Liew, Janice; Grisham, Jessica R; Hayes, Brett K

2018-06-01

This study examined the hypothesis that participants diagnosed with obsessive-compulsive disorder (OCD) show a selective deficit in inductive reasoning but are equivalent to controls in deductive reasoning. Twenty-five participants with OCD and 25 non-clinical controls made inductive and deductive judgments about a common set of arguments that varied in logical validity and the amount of positive evidence provided (premise sample size). A second inductive reasoning task required participants to make forced-choice decisions and rate the usefulness of diverse evidence or non-diverse evidence for evaluating arguments. No differences in deductive reasoning were found between participants diagnosed with OCD and control participants. Both groups saw that the amount of positive evidence supporting a conclusion was an important guide for evaluating inductive arguments. However, those with OCD showed less sensitivity to premise diversity in inductive reasoning than controls. The findings were similar for both emotionally neutral and OCD-relevant stimuli. The absence of a clinical control group means that it is difficult to know whether the deficit in diversity-based reasoning is specific to those with OCD. People with OCD are impaired in some forms of inductive reasoning (using diverse evidence) but not others (use of sample size). Deductive reasoning appears intact in those with OCD. Difficulties using evidence diversity when reasoning inductively may maintain OCD symptoms through reduced generalization of learned safety information. Copyright © 2017 Elsevier Ltd. All rights reserved.

Evaluating moral reasoning in nursing education.

PubMed

McLeod-Sordjan, Renee

2014-06-01

Evidence-based practice suggests the best approach to improving professionalism in practice is ethics curricula. However, recent research has demonstrated that millennium graduates do not advocate for patients or assert themselves during moral conflicts. The aim of this article is the exploration of evaluation techniques to evaluate one measurable outcome of ethics curricula: moral reasoning. A review of literature, published between 1995 and 2013, demonstrated that the moral orientations of care and justice as conceptualized by Gilligan and Kohlberg are utilized by nursing students to solve ethical dilemmas. Data obtained by means of reflective journaling, Ethics of Care Interview (ECI) and Defining Issues Test (DIT), would objectively measure the interrelated pathways of care-based and justice-based moral reasoning. In conclusion, educators have an ethical responsibility to foster students' ability to exercise sound clinical judgment, and support their professional development. It is recommended that educators design authentic assessments to demonstrate student's improvement of moral reasoning. © The Author(s) 2013.

Reasons Why Post-Trial Access to Trial Drugs Should, or Need not be Ensured to Research Participants: A Systematic Review

PubMed Central

Sofaer, Neema; Strech, Daniel

2011-01-01

Background: researchers and sponsors increasingly confront the issue of whether participants in a clinical trial should have post-trial access (PTA) to the trial drug. Legislation and guidelines are inconsistent, ambiguous or silent about many aspects of PTA. Recent research highlights the potential importance of systematic reviews (SRs) of reason-based literatures in informing decision-making in medicine, medical research and health policy. Purpose: to systematically review reasons why drug trial participants should, or need not be ensured PTA to the trial drug and the uses of such reasons. Data sources: databases in science/medicine, law and ethics, thesis databases, bibliographies, research ethics books and included publications’ notes/bibliographies. Publication selection: a publication was included if it included a reason as above. See article for detailed inclusion conditions. Data extraction and analysis: two reviewers extracted and analyzed data on publications and reasons. Results: of 2060 publications identified, 75 were included. These mentioned reasons based on morality, legality, interests/incentives, or practicality, comprising 36 broad (235 narrow) types of reason. None of the included publications, which included informal reviews and reports by official bodies, mentioned more than 22 broad (59 narrow) types. For many reasons, publications differed about the reason’s interpretation, implications and/or persuasiveness. Publications differed also regarding costs, feasibility and legality of PTA. Limitations: reason types could be applied differently. The quality of reasons was not measured. Conclusion: this review captured a greater variety of reasons and of their uses than any included publication. Decisions based on informal reviews or sub-sets of literature are likely to be biased. Research is needed on PTA ethics, costs, feasibility and legality and on assessing the quality of reason-based literature. PMID:21754950

Watch what happens: using a web-based multimedia platform to enhance intraoperative learning and development of clinical reasoning.

PubMed

Fingeret, Abbey L; Martinez, Rebecca H; Hsieh, Christine; Downey, Peter; Nowygrod, Roman

2016-02-01

We aim to determine whether observed operations or internet-based video review predict improved performance in the surgery clerkship. A retrospective review of students' usage of surgical videos, observed operations, evaluations, and examination scores were used to construct an exploratory principal component analysis. Multivariate regression was used to determine factors predictive of clerkship performance. Case log data for 231 students revealed a median of 25 observed cases. Students accessed the web-based video platform a median of 15 times. Principal component analysis yielded 4 factors contributing 74% of the variability with a Kaiser-Meyer-Olkin coefficient of .83. Multivariate regression predicted shelf score (P < .0001), internal clinical skills examination score (P < .0001), subjective evaluations (P < .001), and video website utilization (P < .001) but not observed cases to be significantly associated with overall performance. Utilization of a web-based operative video platform during a surgical clerkship is an independently associated with improved clinical reasoning, fund of knowledge, and overall evaluation. Thus, this modality can serve as a useful adjunct to live observation. Copyright © 2016 Elsevier Inc. All rights reserved.

Factors related to clinical pregnancy after vitrified-warmed embryo transfer: a retrospective and multivariate logistic regression analysis of 2313 transfer cycles.

PubMed

Shi, Wenhao; Zhang, Silin; Zhao, Wanqiu; Xia, Xue; Wang, Min; Wang, Hui; Bai, Haiyan; Shi, Juanzi

2013-07-01

What factors does multivariate logistic regression show to be significantly associated with the likelihood of clinical pregnancy in vitrified-warmed embryo transfer (VET) cycles? Assisted hatching (AH) and if the reason to freeze embryos was to avoid the risk of ovarian hyperstimulation syndrome (OHSS) were significantly positively associated with a greater likelihood of clinical pregnancy. Single factor analysis has shown AH, number of embryos transferred and the reason of freezing for OHSS to be positively and damaged blastomere to be negatively significantly associated with the chance of clinical pregnancy after VET. It remains unclear what factors would be significant after multivariate analysis. The study was a retrospective analysis of 2313 VET cycles from 1481 patients performed between January 2008 and April 2012. A multivariate logistic regression analysis was performed to identify the factors to affect clinical pregnancy outcome of VET. There were 22 candidate variables selected based on clinical experiences and the literature. With the thresholds of α entry = α removal= 0.05 for both variable entry and variable removal, eight variables were chosen to contribute the multivariable model by the bootstrap stepwise variable selection algorithm (n = 1000). Eight variables were age at controlled ovarian hyperstimulation (COH), reason for freezing, AH, endometrial thickness, damaged blastomere, number of embryos transferred, number of good-quality embryos, and blood presence on transfer catheter. A descriptive comparison of the relative importance was accomplished by the proportion of explained variation (PEV). Among the reasons for freezing, the OHSS group showed a higher OR than the surplus embryo group when compared with other reasons for VET groups (OHSS versus Other, OR: 2.145; CI: 1.4-3.286; Surplus embryos versus Other, OR: 1.152; CI: 0.761-1.743) and high PEV (marginal 2.77%, P = 0.2911; partial 1.68%; CI of area under receptor operator characteristic curve (ROC): 0.5576-0.6000). AH also showed a high OR (OR: 2.105, CI: 1.554-2.85) and high PEV (marginal 1.97%; partial 1.02%; CI of area under ROC: 0.5344-0.5647). The number of good-quality embryos showed the highest marginal PEV and partial PEV (marginal 3.91%, partial 2.28%; CI of area under ROC: 0.5886-0.6343). This was a retrospective multivariate analysis of the data obtained in 5 years from a single IVF center. Repeated cycles in the same woman were treated as independent observations, which could introduce bias. Results are based on clinical pregnancy and not live births. Prospective analysis of a larger data set from a multicenter study based on live births is necessary to confirm the findings. Paying attention to the quality of embryos, the number of good embryos, AH and the reasons for freezing that are associated with clinical pregnancy after VET will assist the improvement of success rates.

Differences in clinical reasoning among nurses working in highly specialised paediatric care.

PubMed

Andersson, Nina; Klang, Birgitta; Petersson, Gunilla

2012-03-01

The aim of the study was to examine differences in clinical reasoning among novice, experienced and specialist paediatric nurses. Highly specialised paediatric care requires specific knowledge and ongoing skill performance of the nurses employed. There is a lack of research in how paediatric nurses manage the daily care problems they encounter and how they acquire the skills required to give patients the best possible care. More knowledge is needed about how paediatric nurses with different experience and education reason and communicate about paediatric patient situations. The study was based on six recorded group discussions of a fictitious, but realistic paediatric case. Three categories of nurses: novices (n = 7), experienced (n = 7) and specialists (n = 7) from a paediatric hospital participated. A qualitative content analysis approach was chosen to examine differences in clinical reasoning. Several themes were uncovered: child's social situation, child abuse and the child's illness, qualitative differences emerged in how the nurses discussed the case. Three approaches were identified: a task-oriented approach (novices and experienced), an action-oriented approach (novices and experienced) and hypothesis-oriented approach (specialists) while discussing the case. When comparing nurses in three competence groups, it was established that the groups with extensive experience and specialist education reasoned differently than the other groups. Between the novice and experienced groups, no obvious differences were found. Thus, the importance of experience alone for the development of competence is still an open question. Experience combined with further education appears important for developing professional competence in paediatric care. Nurses' reasoning in clinical paediatric care is related to experience and training. © 2012 Blackwell Publishing Ltd.

A qualitative study of clinical reasoning in physiotherapy with preterm infants and their parents: Action and interaction.

PubMed

Håkstad, Ragnhild B; Obstfelder, Aud; Øberg, Gunn Kristin

2018-09-01

Physiotherapists (PTs) in primary health care provide services to preterm infants and their parents after hospital discharge. The service should be collaborative and individualized to meet the family's needs. In this study, we analyze pediatric PTs' collaborative work in the clinical setting and investigate the PTs' emerging clinical reasoning (CR) in interaction with the infant and parent(s). The study is based on observations of 20 physical therapy sessions and 20 interviews with PTs. We performed a systematic content analysis informed by enactive theory regarding the interactions and co-creation of meaning. CR emerged in reciprocity with the PTs' interaction with the infant and parent(s). Based on the sensitivity to the infant's motor abilities and signs of engagement as well as the parents' need of support and education, the PTs individualized and reasoned about their therapeutic approach. This interactional CR was vulnerable: infant disengagement, parent expectations, and PT preoccupations could obfuscate interactions and hamper CR. Through mutuality and engagement with the infant and parent(s), the PTs allow the autonomy of interaction to emerge and shape the translation of CR into successful therapeutic actions and learning together with the infant and parent(s).

Design principles for simulation games for learning clinical reasoning: A design-based research approach.

PubMed

Koivisto, J-M; Haavisto, E; Niemi, H; Haho, P; Nylund, S; Multisilta, J

2018-01-01

Nurses sometimes lack the competence needed for recognising deterioration in patient conditions and this is often due to poor clinical reasoning. There is a need to develop new possibilities for learning this crucial competence area. In addition, educators need to be future oriented; they need to be able to design and adopt new pedagogical innovations. The purpose of the study is to describe the development process and to generate principles for the design of nursing simulation games. A design-based research methodology is applied in this study. Iterative cycles of analysis, design, development, testing and refinement were conducted via collaboration among researchers, educators, students, and game designers. The study facilitated the generation of reusable design principles for simulation games to guide future designers when designing and developing simulation games for learning clinical reasoning. This study makes a major contribution to research on simulation game development in the field of nursing education. The results of this study provide important insights into the significance of involving nurse educators in the design and development process of educational simulation games for the purpose of nursing education. Copyright © 2017 Elsevier Ltd. All rights reserved.

A prognostic model for temporal courses that combines temporal abstraction and case-based reasoning.

PubMed

Schmidt, Rainer; Gierl, Lothar

2005-03-01

Since clinical management of patients and clinical research are essentially time-oriented endeavours, reasoning about time has become a hot topic in medical informatics. Here we present a method for prognosis of temporal courses, which combines temporal abstractions with case-based reasoning. It is useful for application domains where neither well-known standards, nor known periodicity, nor a complete domain theory exist. We have used our method in two prognostic applications. The first one deals with prognosis of the kidney function for intensive care patients. The idea is to elicit impairments on time, especially to warn against threatening kidney failures. Our second application deals with a completely different domain, namely geographical medicine. Its intention is to compute early warnings against approaching infectious diseases, which are characterised by irregular cyclic occurrences. So far, we have applied our program on influenza and bronchitis. In this paper, we focus on influenza forecast and show first experimental results.

Articular dysfunction patterns in patients with mechanical neck pain: a clinical algorithm to guide specific mobilization and manipulation techniques.

PubMed

Dewitte, Vincent; Beernaert, Axel; Vanthillo, Bart; Barbe, Tom; Danneels, Lieven; Cagnie, Barbara

2014-02-01

In view of a didactical approach for teaching cervical mobilization and manipulation techniques to students as well as their use in daily practice, it is mandatory to acquire sound clinical reasoning to optimally apply advanced technical skills. The aim of this Masterclass is to present a clinical algorithm to guide (novice) therapists in their clinical reasoning to identify patients who are likely to respond to mobilization and/or manipulation. The presented clinical reasoning process is situated within the context of pain mechanisms and is narrowed to and applicable in patients with a dominant input pain mechanism. Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities. Copyright © 2013 Elsevier Ltd. All rights reserved.

Reasoning Backwards by Design: Commentary on "Moral Reasoning among HEC Members".

PubMed

Stephens, Ashley L; Heitman, Elizabeth

2015-01-01

Empirical assessment of the practice of clinical ethics is made difficult by the limited standardization of settings, structures, processes, roles, and training for ethics consultation, as well as by whether individual ethics consultants or hospital ethics committees (HECs) provide consultation. Efforts to study the relationship between theory and practice in the work of HECs likewise require the spelling out of assumptions and definition of key variables, based in knowledge of the core concepts of clinical ethics and logistics of clinical consultation. The survey of HEC members reported by Wasserman and colleagues illustrates the difficulty of such research and calls attention to need for studies of real-time, complex decision making to inform conclusions about how theory affects practice. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Limited clinical reasoning skills used by novice physiotherapists when involved in the assessment and management of patients with shoulder problems: a qualitative study

PubMed Central

May, Stephen; Withers, Sarah; Reeve, Sarah; Greasley, Alison

2010-01-01

The aim of this study was to explore the clinical reasoning process used by novice physical therapists in specific patient problems. Nine physical therapists in the UK with limited experience of managing musculoskeletal problems were included. Semi-structured interviews were conducted on how novice physical therapists would assess and manage a patient with a shoulder problem; interviews were transcribed and analyzed using framework analysis. To be included as a final theme at least 50% of participants had to mention that theme. A large number of items (n = 93) were excluded as fewer than 50% of participants referred to each item. Included items related to seven main themes: history (16), physical exam (13), investigations (1), diagnostic reasoning (1), clinical reasoning process (diagnostic pathway) (3), clinical reasoning process (management pathway) (5) and treatment options (1). Items mostly related to information gathering, although there was some use of hypothetico-deductive clinical reasoning there appeared to be limited understanding of the clinical implications of data gathered, and clinical reasoning through use of pattern recognition was minimal. Major weaknesses were apparent in the clinical reasoning skills of these novice therapists compared to previous reports of expert clinical reasoning, indicating areas for development in the education of student and junior physical therapists. PMID:21655390

Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors.

PubMed

Rencic, Joseph; Trowbridge, Robert L; Fagan, Mark; Szauter, Karen; Durning, Steven

2017-11-01

Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. Cross-sectional multicenter study. US institutional members of the Clerkship Directors in Internal Medicine (CDIM). Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.

Clinical reasoning: concept analysis.

PubMed

Simmons, Barbara

2010-05-01

This paper is a report of a concept analysis of clinical reasoning in nursing. Clinical reasoning is an ambiguous term that is often used synonymously with decision-making and clinical judgment. Clinical reasoning has not been clearly defined in the literature. Healthcare settings are increasingly filled with uncertainty, risk and complexity due to increased patient acuity, multiple comorbidities, and enhanced use of technology, all of which require clinical reasoning. Data sources. Literature for this concept analysis was retrieved from several databases, including CINAHL, PubMed, PsycINFO, ERIC and OvidMEDLINE, for the years 1980 to 2008. Rodgers's evolutionary method of concept analysis was used because of its applicability to concepts that are still evolving. Multiple terms have been used synonymously to describe the thinking skills that nurses use. Research in the past 20 years has elucidated differences among these terms and identified the cognitive processes that precede judgment and decision-making. Our concept analysis defines one of these terms, 'clinical reasoning,' as a complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyse patient information, evaluate its significance, and weigh alternative actions. This concept analysis provides a middle-range descriptive theory of clinical reasoning in nursing that helps clarify meaning and gives direction for future research. Appropriate instruments to operationalize the concept need to be developed. Research is needed to identify additional variables that have an impact on clinical reasoning and what are the consequences of clinical reasoning in specific situations.

Evolution of Students' Reasoning Skills on a Two Year Basis in a PBL Curriculum in Medicine.

ERIC Educational Resources Information Center

Bedard, Denis; And Others

A 2-year study at the University of Sherbrooke (Quebec) investigated the changes in six medical students' clinical reasoning processes as they participated in a problem-based learning (PBL) curriculum. In each year, students performed a think-aloud protocol with two medical case problems to solve, one in cardiology and one in urology. In the…

Clinical reasoning and critical thinking.

PubMed

da Silva Bastos Cerullo, Josinete Aparecida; de Almeida Lopes Monteiro da Cruz, Diná

2010-01-01

This study identifies and analyzes nursing literature on clinical reasoning and critical thinking. A bibliographical search was performed in LILACS, SCIELO, PUBMED and CINAHL databases, followed by selection of abstracts and the reading of full texts. Through the review we verified that clinical reasoning develops from scientific and professional knowledge, is permeated by ethical decisions and nurses values and also that there are different personal and institutional strategies that might improve the critical thinking and clinical reasoning of nurses. Further research and evaluation of educational programs on clinical reasoning that integrate psychosocial responses to physiological responses of people cared by nurses is needed.

Pathologists' roles in clinical utilization management. A financing model for managed care.

PubMed

Zhao, J J; Liberman, A

2000-03-01

In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists' potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist's contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system-based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages.

An integrated model of clinical reasoning: dual-process theory of cognition and metacognition.

PubMed

Marcum, James A

2012-10-01

Clinical reasoning is an important component for providing quality medical care. The aim of the present paper is to develop a model of clinical reasoning that integrates both the non-analytic and analytic processes of cognition, along with metacognition. The dual-process theory of cognition (system 1 non-analytic and system 2 analytic processes) and the metacognition theory are used to develop an integrated model of clinical reasoning. In the proposed model, clinical reasoning begins with system 1 processes in which the clinician assesses a patient's presenting symptoms, as well as other clinical evidence, to arrive at a differential diagnosis. Additional clinical evidence, if necessary, is acquired and analysed utilizing system 2 processes to assess the differential diagnosis, until a clinical decision is made diagnosing the patient's illness and then how best to proceed therapeutically. Importantly, the outcome of these processes feeds back, in terms of metacognition's monitoring function, either to reinforce or to alter cognitive processes, which, in turn, enhances synergistically the clinician's ability to reason quickly and accurately in future consultations. The proposed integrated model has distinct advantages over other models proposed in the literature for explicating clinical reasoning. Moreover, it has important implications for addressing the paradoxical relationship between experience and expertise, as well as for designing a curriculum to teach clinical reasoning skills. © 2012 Blackwell Publishing Ltd.

A cognitive perspective on medical expertise: theory and implication.

PubMed

Schmidt, H G; Norman, G R; Boshuizen, H P

1990-10-01

A new theory of the development of expertise in medicine is outlined. Contrary to existing views, this theory assumes that expertise is not so much a matter of superior reasoning skills or in-depth knowledge of pathophysiological states as it is based on cognitive structures that describe the features of prototypical or even actual patients. These cognitive structures, referred to as "illness scripts," contain relatively little knowledge about pathophysiological causes of symptoms and complaints but a wealth of clinically relevant information about disease, its consequences, and the context under which illness develops. By contrast, intermediate-level students without clinical experience typically use pathophysiological, causal models of disease when solving problems. The authors review evidence supporting the theory and discuss its implications for the understanding of five phenomena extensively documented in the clinical-reasoning literature: (1) content specificity in diagnostic performance; (2) typical differences in data-gathering techniques between medical students and physicians; (3) difficulties involved in setting standards; (4) a decline in performance on certain measures of clinical reasoning with increasing expertise; and (5) a paradoxical association between errors and longer response times in visual diagnosis.

Pregnancy and Protection: The Ethics of Limiting a Pregnant Woman’s Participation in Clinical Trials

PubMed Central

Allesee, Lori; Gallagher, Colleen M.

2011-01-01

The call for the inclusion of pregnant women in clinical trials has received renewed attention recently. This interest springs from articles in various medical journals highlighting the gaps in medical knowledge and the need to improve health care for pregnant women. It is not a simple decision whether to include pregnant women in studies or not. The general thought is that it’s too dangerous for the baby if a pregnant woman is participating in a trial, and the absence of research on how medications work in pregnant women leave doctors guessing about how to safely and effectively treat patients through pregnancy. Excluding pregnant women from clinical trials are not automatic, not unethical nor is it arbitrarily determined. The regulatory framework is based on sound ethical and legal reasoning that demonstrates when inclusion in a clinical trial is appropriate or when clear and compelling reasons for exclusion are presented. Learning objective Readers will learn about limitations of research, history of the inclusion and exclusion of pregnant women in clinical trials, reticence for inclusions, as well as regulations designed using reasoned legal and ethical principles, such as: Principle of Autonomy, Informed Consent, and Beneficence and Nonmaleficence. PMID:21863146

Clarifying assumptions to enhance our understanding and assessment of clinical reasoning.

PubMed

Durning, Steven J; Artino, Anthony R; Schuwirth, Lambert; van der Vleuten, Cees

2013-04-01

Deciding on a diagnosis and treatment is essential to the practice of medicine. Developing competence in these clinical reasoning processes, commonly referred to as diagnostic and therapeutic reasoning, respectively, is required for physician success. Clinical reasoning has been a topic of research for several decades, and much has been learned. However, there still exists no clear consensus regarding what clinical reasoning entails, let alone how it might best be taught, how it should be assessed, and the research and practice implications therein.In this article, the authors first discuss two contrasting epistemological views of clinical reasoning and related conceptual frameworks. They then outline four different theoretical frameworks held by medical educators that the authors believe guide educators' views on the topic, knowingly or not. Within each theoretical framework, the authors begin with a definition of clinical reasoning (from that viewpoint) and then discuss learning, assessment, and research implications. The authors believe these epistemologies and four theoretical frameworks also apply to other concepts (or "competencies") in medical education.The authors also maintain that clinical reasoning encompasses the mental processes and behaviors that are shared (or evolve) between the patient, physician, and the environment (i.e., practice setting). Clinical reasoning thus incorporates components of all three factors (patient, physician, environment). The authors conclude by outlining practical implications and potential future areas for research.

Intelligent diagnosis of jaundice with dynamic uncertain causality graph model.

PubMed

Hao, Shao-Rui; Geng, Shi-Chao; Fan, Lin-Xiao; Chen, Jia-Jia; Zhang, Qin; Li, Lan-Juan

2017-05-01

Jaundice is a common and complex clinical symptom potentially occurring in hepatology, general surgery, pediatrics, infectious diseases, gynecology, and obstetrics, and it is fairly difficult to distinguish the cause of jaundice in clinical practice, especially for general practitioners in less developed regions. With collaboration between physicians and artificial intelligence engineers, a comprehensive knowledge base relevant to jaundice was created based on demographic information, symptoms, physical signs, laboratory tests, imaging diagnosis, medical histories, and risk factors. Then a diagnostic modeling and reasoning system using the dynamic uncertain causality graph was proposed. A modularized modeling scheme was presented to reduce the complexity of model construction, providing multiple perspectives and arbitrary granularity for disease causality representations. A "chaining" inference algorithm and weighted logic operation mechanism were employed to guarantee the exactness and efficiency of diagnostic reasoning under situations of incomplete and uncertain information. Moreover, the causal interactions among diseases and symptoms intuitively demonstrated the reasoning process in a graphical manner. Verification was performed using 203 randomly pooled clinical cases, and the accuracy was 99.01% and 84.73%, respectively, with or without laboratory tests in the model. The solutions were more explicable and convincing than common methods such as Bayesian Networks, further increasing the objectivity of clinical decision-making. The promising results indicated that our model could be potentially used in intelligent diagnosis and help decrease public health expenditure.

Intelligent diagnosis of jaundice with dynamic uncertain causality graph model*

PubMed Central

Hao, Shao-rui; Geng, Shi-chao; Fan, Lin-xiao; Chen, Jia-jia; Zhang, Qin; Li, Lan-juan

2017-01-01

Jaundice is a common and complex clinical symptom potentially occurring in hepatology, general surgery, pediatrics, infectious diseases, gynecology, and obstetrics, and it is fairly difficult to distinguish the cause of jaundice in clinical practice, especially for general practitioners in less developed regions. With collaboration between physicians and artificial intelligence engineers, a comprehensive knowledge base relevant to jaundice was created based on demographic information, symptoms, physical signs, laboratory tests, imaging diagnosis, medical histories, and risk factors. Then a diagnostic modeling and reasoning system using the dynamic uncertain causality graph was proposed. A modularized modeling scheme was presented to reduce the complexity of model construction, providing multiple perspectives and arbitrary granularity for disease causality representations. A “chaining” inference algorithm and weighted logic operation mechanism were employed to guarantee the exactness and efficiency of diagnostic reasoning under situations of incomplete and uncertain information. Moreover, the causal interactions among diseases and symptoms intuitively demonstrated the reasoning process in a graphical manner. Verification was performed using 203 randomly pooled clinical cases, and the accuracy was 99.01% and 84.73%, respectively, with or without laboratory tests in the model. The solutions were more explicable and convincing than common methods such as Bayesian Networks, further increasing the objectivity of clinical decision-making. The promising results indicated that our model could be potentially used in intelligent diagnosis and help decrease public health expenditure. PMID:28471111

ClinGen Pathogenicity Calculator: a configurable system for assessing pathogenicity of genetic variants.

PubMed

Patel, Ronak Y; Shah, Neethu; Jackson, Andrew R; Ghosh, Rajarshi; Pawliczek, Piotr; Paithankar, Sameer; Baker, Aaron; Riehle, Kevin; Chen, Hailin; Milosavljevic, Sofia; Bizon, Chris; Rynearson, Shawn; Nelson, Tristan; Jarvik, Gail P; Rehm, Heidi L; Harrison, Steven M; Azzariti, Danielle; Powell, Bradford; Babb, Larry; Plon, Sharon E; Milosavljevic, Aleksandar

2017-01-12

The success of the clinical use of sequencing based tests (from single gene to genomes) depends on the accuracy and consistency of variant interpretation. Aiming to improve the interpretation process through practice guidelines, the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) have published standards and guidelines for the interpretation of sequence variants. However, manual application of the guidelines is tedious and prone to human error. Web-based tools and software systems may not only address this problem but also document reasoning and supporting evidence, thus enabling transparency of evidence-based reasoning and resolution of discordant interpretations. In this report, we describe the design, implementation, and initial testing of the Clinical Genome Resource (ClinGen) Pathogenicity Calculator, a configurable system and web service for the assessment of pathogenicity of Mendelian germline sequence variants. The system allows users to enter the applicable ACMG/AMP-style evidence tags for a specific allele with links to supporting data for each tag and generate guideline-based pathogenicity assessment for the allele. Through automation and comprehensive documentation of evidence codes, the system facilitates more accurate application of the ACMG/AMP guidelines, improves standardization in variant classification, and facilitates collaborative resolution of discordances. The rules of reasoning are configurable with gene-specific or disease-specific guideline variations (e.g. cardiomyopathy-specific frequency thresholds and functional assays). The software is modular, equipped with robust application program interfaces (APIs), and available under a free open source license and as a cloud-hosted web service, thus facilitating both stand-alone use and integration with existing variant curation and interpretation systems. The Pathogenicity Calculator is accessible at http://calculator.clinicalgenome.org . By enabling evidence-based reasoning about the pathogenicity of genetic variants and by documenting supporting evidence, the Calculator contributes toward the creation of a knowledge commons and more accurate interpretation of sequence variants in research and clinical care.

Subject preferences of first- and second-year medical students for their future specialization at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal – a questionnaire-based study

PubMed Central

Jha, Rajesh K; Paudel, Keshab R; Shah, Dev K; Sah, Ajit K; Basnet, Sangharshila; Sah, Phoolgen; Adhikari, Sandeep

2015-01-01

Introduction The selection of a discipline for future specialization may be an important factor for the medical students’ future career, and it is influenced by multiple factors. The interest of students in the early stages can be improved in subjects related to public health or of academic importance, as per need. Methods A questionnaire-based study was conducted among 265 first- and second-year medical students of Chitwan Medical College, Nepal to find out their subject of preference for postgraduation and the factors affecting their selection along with their interesting basic science subject. Only the responses from 232 completely filled questionnaires were analyzed. Results The preference of the students for clinical surgical (50.9%), clinical medical (45.3%), and basic medical (3.9%) sciences for postgraduation were in descending order. The most preferred specialty among male students was clinical surgical sciences (56.3%), and among female students, it was clinical medical sciences (53.6%). Although all the students responded to their preferred specialty, only 178 students specified the subject of their interest. General surgery (23.4%), pediatrics (23.4%), and anatomy (2.4%) were the most favored subjects for postgraduation among clinical surgical, clinical medical, and basic medical sciences specialties, respectively. More common reasons for selection of specific subject for future career were found to be: personal interests, good income, intellectual challenge, and others. Conclusion Many students preferred clinical surgical sciences for their future specialization. Among the reasons for the selection of the specialty for postgraduation, no significant reason could be elicited from the present study. PMID:26635491

Disgust- and anxiety-based emotional reasoning in non-clinical fear of vomiting.

PubMed

Verwoerd, Johan; van Hout, Wiljo J P J; de Jong, Peter J

2016-03-01

Emotional reasoning has been described as a dysfunctional tendency to use subjective responses to make erroneous inferences about threatening outcomes in objectively safe situations (e.g., "If I feel anxious/disgusted, there must be danger/risk of becoming ill"). Prior studies found evidence for anxiety-based emotional reasoning (ER) in several anxiety disorders as well as disgust-based ER in healthy individuals scoring above the clinical cut-off on a measure of contamination fear. The current study tested whether disgust- and anxiety-based ER might be involved in fear of vomiting, a phobic disorder in which both fear/anxiety and disgust are assumed to play an important role. Non-clinical participants scoring high (>75%; n = 35) and low (<25%; n = 38) on a measure of fear of vomiting were presented with a series of scripts describing objectively safe everyday situations that systematically varied in the absence/presence of the actor's disgust/anxiety response. Following each script, participants rated their perceived danger and threat of contamination/illness. In line with hypotheses, specifically high vomit-fearful individuals used experienced disgust and anxiety to overestimate risk of becoming ill. Follow up analyses taking into account shared variance between both emotions revealed that more pronounced ER in the high vomit fearful group was mainly driven by the emotion of disgust. Current study asked participants to imagine experienced emotions in scenarios instead of experimentally inducing real-life emotions. These findings are consistent with the view that disgust-based ER is involved in fear of vomiting. Copyright © 2015 Elsevier Ltd. All rights reserved.

Clinical ethics and happiness.

PubMed

Devettere, R J

1993-02-01

Most contemporary accounts of clinical ethics do not explain why clinicians should be ethical. Those few that do attempt an explanation usually claim that clinicians should be ethical because ethical behavior provides an important good for the patient--better care. Both these approaches ignore the customary traditional reason for being ethical, namely, the good of the moral agent. This good was commonly called 'happiness'. The following article shows how the personal happiness of the moral agent provided a major reason for being ethical in the ancient philosophical and biblical traditions and how it continues to play a role in the more modern rights-based, Kantian and utilitarian theories. This history suggests that the personal happiness of the clinician, rightly understood, is a legitimate and important goal of clinical ethics.

Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game.

PubMed

Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild

2016-10-01

Serious games (SGs) are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care. This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease (COPD) in home healthcare settings. A prototype SG was developed. A unified framework of usability called TURF (Task, User, Representation, and Function) and SG theory were employed to ensure a user-centered design. The educational content was based on the clinical decision-making model, Bloom's taxonomy, and a Bachelor of Nursing curriculum. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory. Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation. The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users. Usability issues regarding functionality and the user-computer interface design were identified. However, the SG was perceived as being easy to learn, and participants suggested that the SG could serve as a supplement to traditional training in laboratory and clinical settings. Using video based scenarios with an authentic COPD patient and a home healthcare registered nurse as actors contributed to increased realism. Using different theoretical approaches in the SG design was considered an advantage of the design process. The SG was perceived as being useful, usable, and satisfying. The achievement of the desired functionality and the minimization of user-computer interface issues emphasize the importance of conducting a usability evaluation during the SG development process. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Community-based faculty: motivation and rewards.

PubMed

Fulkerson, P K; Wang-Cheng, R

1997-02-01

The reasons why practicing physicians precept students in their offices, and the rewards they wish to receive for this work, have not been clearly elucidated. This study determined the reasons for precepting and the rewards expected among a network of preceptors in Milwaukee. A questionnaire was mailed to 120 community-based physician preceptors in a required, third-year ambulatory care clerkship. Respondents were asked to identify why they volunteered and what they considered appropriate recognition or reward. The personal satisfaction derived from the student-teacher interaction was, by far, the most important motivator for preceptors (84%). The most preferred rewards for teaching included clinical faculty appointment, CME and bookstore discounts, computer networking, and workshops for improving skills in clinical teaching. Community-based private physicians who participate in medical student education programs are primarily motivated by the personal satisfaction that they derive from the teaching encounter. An effective preceptor recognition/reward program can be developed using input from the preceptors themselves.

Design and Evaluation of an Electronic Override Mechanism for Medication Alerts to Facilitate Communication Between Prescribers and Pharmacists.

PubMed

Russ, Alissa L; Chen, Siying; Melton, Brittany L; Saleem, Jason J; Weiner, Michael; Spina, Jeffrey R; Daggy, Joanne K; Zillich, Alan J

2015-07-01

Computerized medication alerts can often be bypassed by entering an override rationale, but prescribers' override reasons are frequently ambiguous to pharmacists who review orders. To develop and evaluate a new override mechanism for adverse reaction and drug-drug interaction alerts. We hypothesized that the new mechanism would improve usability for prescribers and increase the clinical appropriateness of override reasons. A counterbalanced, crossover study was conducted with 20 prescribers in a simulated prescribing environment. We modified the override mechanism timing, navigation, and text entry. Instead of free-text entry, the new mechanism presented prescribers with a predefined set of override reasons. We assessed usability (learnability, perceived efficiency, and usability errors) and used a priori criteria to evaluate the clinical appropriateness of override reasons entered. Prescribers rated the new mechanism as more efficient (Wilcoxon signed-rank test, P = 0.032). When first using the new design, 5 prescribers had difficulty finding the new mechanism, and 3 interpreted the navigation to mean that the alert could not be overridden. The number of appropriate override reasons significantly increased with the new mechanism compared with the original mechanism (median change of 3.0; interquartile range = 3.0; P < 0.0001). When prescribers were given a menu-based choice for override reasons, clinical appropriateness of these reasons significantly improved. Further enhancements are necessary, but this study is an important first step toward a more standardized menu of override choices. Findings may be used to improve communication through e-prescribing systems between prescribers and pharmacists. © The Author(s) 2015.

An intelligent interactive simulator of clinical reasoning in general surgery.

PubMed Central

Wang, S.; el Ayeb, B.; Echavé, V.; Preiss, B.

1993-01-01

We introduce an interactive computer environment for teaching in general surgery and for diagnostic assistance. The environment consists of a knowledge-based system coupled with an intelligent interface that allows users to acquire conceptual knowledge and clinical reasoning techniques. Knowledge is represented internally within a probabilistic framework and externally through a interface inspired by Concept Graphics. Given a set of symptoms, the internal knowledge framework computes the most probable set of diseases as well as best alternatives. The interface displays CGs illustrating the results and prompting essential facts of a medical situation or a process. The system is then ready to receive additional information or to suggest further investigation. Based on the new information, the system will narrow the solutions with increased belief coefficients. PMID:8130508

Psychometric characteristics of Clinical Reasoning Problems (CRPs) and its correlation with routine multiple choice question (MCQ) in Cardiology department

PubMed Central

DERAKHSHANDEH, ZAHRA; AMINI, MITRA; KOJURI, JAVAD; DEHBOZORGIAN, MARZIYEH

2018-01-01

Introduction: Clinical reasoning is one of the most important skills in the process of training a medical student to become an efficient physician. Assessment of the reasoning skills in a medical school program is important to direct students’ learning. One of the tests for measuring the clinical reasoning ability is Clinical Reasoning Problems (CRPs). The major aim of this study is to measure psychometric qualities of CRPs and define correlation between this test and routine MCQ in cardiology department of Shiraz medical school. Methods: This study was a descriptive study conducted on total cardiology residents of Shiraz Medical School. The study population consists of 40 residents in 2014. The routine CRPs and the MCQ tests was designed based on similar objectives and were carried out simultaneously. Reliability, item difficulty, item discrimination, and correlation between each item and the total score of CRPs were all measured by Excel and SPSS software for checking psycometeric CRPs test. Furthermore, we calculated the correlation between CRPs test and MCQ test. The mean differences of CRPs test score between residents’ academic year [second, third and fourth year] were also evaluated by Analysis of variances test (One Way ANOVA) using SPSS software (version 20)(α=0.05). Results: The mean and standard deviation of score in CRPs was 10.19 ±3.39 out of 20; in MCQ, it was 13.15±3.81 out of 20. Item difficulty was in the range of 0.27-0.72; item discrimination was 0.30-0.75 with question No.3 being the exception (that was 0.24). The correlation between each item and the total score of CRP was 0.26-0.87; the correlation between CRPs test and MCQ test was 0.68 (p<0.001). The reliability of the CRPs was 0.72 as calculated by using Cronbach's alpha. The mean score of CRPs was different among residents based on their academic year and this difference was statistically significant (p<0.001). Conclusion: The results of this present investigation revealed that CRPs could be reliable test for measuring clinical reasoning in residents. It can be included in cardiology residency assessment programs. PMID:29344528

Clinical reasoning skills in final-year dental students: A qualitative cross-curricula comparison.

PubMed

Nafea, E T; Dennick, R

2018-05-01

The aim of this research was to explore the perceptions of undergraduate dental students regarding clinical reasoning skills and also discover the influences of different curriculum designs on the acquisition of these skills by students. Eighteen final-year students from three different dental schools with varied curricula and cultures participated in the current research. The research used qualitative methodology. The study took place in 2013-2014. Interviews captured the participants' own understanding of clinical reasoning and its acquisition plus they "talked through" a clinical problem using a "think-aloud" technique. Thematic analysis was used to analyse the transcripts of the recorded interviews. Results obtained were related to curriculum structure. Unfamiliarity with the term clinical reasoning was common in students. Students from different schools used different strategies to reason when discussing clinical vignettes. Clinical reasoning process was dominated by pattern recognition. Students' behaviours seemed to be influenced by cultural factors. This research contributes to a greater understanding of how students learn, understand and apply dental clinical reasoning which will improve educational practices in the future. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Most children with cancer are not enrolled on a clinical trial in Canada: a population-based study.

PubMed

Pole, Jason D; Barber, Randy; Bergeron, Rose-Émilie; Carret, Anne Sophie; Dix, David; Kulkarni, Ketan; Martineau, Emilie; Randall, Alicia; Stammers, David; Strahlendorf, Caron; Strother, Douglas R; Truong, Tony H; Sung, Lillian

2017-06-05

Primary objective was to describe the proportion of children newly diagnosed with cancer enrolled on a therapeutic clinical trial. Secondary objectives were to describe reasons for non-enrollment and factors associated with enrollment on trials. In this retrospective cohort study, we included children newly diagnosed with cancer between 0 and 14 years of age and diagnosed from 2001 to 2012. We used data from the Cancer in Young People in Canada (CYP-C) national pediatric cancer population-based database. CYP-C captures all cases of pediatric cancer (0-14 years) diagnosed and treated at one of the 17 tertiary pediatric oncology centers in Canada. Non-enrollment was evaluated using univariate and multiple logistic regression analysis. There were 9204 children with cancer included, of whom 2533 (27.5%) were enrolled on a clinical trial. The most common reasons cited for non-enrollment were lack of an available trial (52.2%) and physician choice (11.2%). In multiple regression, Asian and Arab/west Asian race were associated with lower enrollment (P = 0.006 and P = 0.032 respectively). All cancer diagnoses were more likely to be enrolled compared to astrocytoma and children with acute lymphoblastic leukemia had an almost 18-fold increased odds of enrollment compared to astrocytoma (P < 0.0001). Greater distance from the tertiary care center was independently associated with non-enrollment (P < 0.0001). In Canada, 27.5% of children with cancer are enrolled onto therapeutic clinical trials and lack of an available trial is the most common reason contributing to non-enrollment. Future research should better understand reasons for lack of trial availability and physician preferences to not offer trials.

A Clinician's Approach to Clinical Ethical Reasoning

PubMed Central

Kaldjian, Lauris C; Weir, Robert F; Duffy, Thomas P

2005-01-01

We offer a systematic strategy that situates clinical ethical reasoning within the paradigm of clinical reasoning. The trajectory of this strategy parallels clinical reasoning: a plain statement of the initial problem, careful gathering of data, a differential diagnostic assessment, and articulation and confirmation of a justified plan. This approach pays special attention to the goals of medical care, because so much depends on whether or not physician and patient share the same goals. This approach also addresses the heterogeneity of clinical problems that at first appear ethical and acknowledges the ethical pluralism that pervades clinical ethics. PMID:15836537

Clinical reasoning and case-based decision making: the fundamental challenge to veterinary educators.

PubMed

May, Stephen A

2013-01-01

Confusion about the nature of human reasoning and its appropriate application to patients has hampered veterinary students' development of these skills. Expertise is associated with greater ability to deploy pattern recognition (type 1 reasoning), which is aided by progressive development of data-driven, forward reasoning (in contrast to scientific, backward reasoning), analytical approaches that lead to schema acquisition. The associative nature of type 1 reasoning makes it prone to bias, particularly in the face of "cognitive miserliness," when clues that indicate the need for triangulation with an analytical approach are ignored. However, combined reasoning approaches, from the earliest stages, are more successful than one approach alone, so it is important that those involved in curricular design and delivery promote student understanding of reasoning generally, and the situations in which reasoning goes awry, and develop students' ability to reason safely and accurately whether presented with a familiar case or with a case that they have never seen before.

32 CFR 220.8 - Reasonable charges.

Code of Federal Regulations, 2013 CFR

2013-07-01

... standardized amounts, one for large urban, other urban/rural, and overseas area, utilizing the same... certain medications when these services are provided in a separate immunizations or shot clinic, are based...

32 CFR 220.8 - Reasonable charges.

Code of Federal Regulations, 2014 CFR

2014-07-01

... standardized amounts, one for large urban, other urban/rural, and overseas area, utilizing the same... certain medications when these services are provided in a separate immunizations or shot clinic, are based...

32 CFR 220.8 - Reasonable charges.

Code of Federal Regulations, 2011 CFR

2011-07-01

... standardized amounts, one for large urban, other urban/rural, and overseas area, utilizing the same... certain medications when these services are provided in a separate immunizations or shot clinic, are based...

32 CFR 220.8 - Reasonable charges.

Code of Federal Regulations, 2010 CFR

2010-07-01

... standardized amounts, one for large urban, other urban/rural, and overseas area, utilizing the same... certain medications when these services are provided in a separate immunizations or shot clinic, are based...

What every teacher needs to know about clinical reasoning.

PubMed

Eva, Kevin W

2005-01-01

One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.

The Validation of the Active Learning in Health Professions Scale

ERIC Educational Resources Information Center

Kammer, Rebecca; Schreiner, Laurie; Kim, Young K.; Denial, Aurora

2015-01-01

There is a need for an assessment tool for evaluating the effectiveness of active learning strategies such as problem-based learning in promoting deep learning and clinical reasoning skills within the dual environments of didactic and clinical settings in health professions education. The Active Learning in Health Professions Scale (ALPHS)…

Observable phenomena that reveal medical students' clinical reasoning ability during expert assessment of their history taking: a qualitative study.

PubMed

Haring, Catharina M; Cools, Bernadette M; van Gurp, Petra J M; van der Meer, Jos W M; Postma, Cornelis T

2017-08-29

During their clerkships, medical students are meant to expand their clinical reasoning skills during their patient encounters. Observation of these encounters could reveal important information on the students' clinical reasoning abilities, especially during history taking. A grounded theory approach was used to analyze what expert physicians apply as indicators in their assessment of medical students' diagnostic reasoning abilities during history taking. Twelve randomly selected clinical encounter recordings of students at the end of the internal medicine clerkships were observed by six expert assessors, who were prompted to formulate their assessment criteria in a think-aloud procedure. These formulations were then analyzed to identify the common denominators and leading principles. The main indicators of clinical reasoning ability were abstracted from students' observable acts during history taking in the encounter. These were: taking control, recognizing and responding to relevant information, specifying symptoms, asking specific questions that point to pathophysiological thinking, placing questions in a logical order, checking agreement with patients, summarizing and body language. In addition, patients' acts and the course, result and efficiency of the conversation were identified as indicators of clinical reasoning, whereas context, using self as a reference, and emotion/feelings were identified by the clinicians as variables in their assessment of clinical reasoning. In observing and assessing clinical reasoning during history taking by medical students, general and specific phenomena to be used as indicators for this process could be identified. These phenomena can be traced back to theories on the development and the process of clinical reasoning.

Clinical Reasoning Tasks and Resident Physicians: What Do They Reason About?

PubMed

McBee, Elexis; Ratcliffe, Temple; Goldszmidt, Mark; Schuwirth, Lambert; Picho, Katherine; Artino, Anthony R; Masel, Jennifer; Durning, Steven J

2016-07-01

A framework of clinical reasoning tasks thought to occur in a clinical encounter was recently developed. It proposes that diagnostic and therapeutic reasoning comprise 24 tasks. The authors of this current study used this framework to investigate what internal medicine residents reason about when they approach straightforward clinical cases. Participants viewed three video-recorded clinical encounters portraying common diagnoses. After each video, participants completed a post encounter form and think-aloud protocol. Two authors analyzed transcripts from the think-aloud protocols using a constant comparative approach. They conducted iterative coding of the utterances, classifying each according to the framework of clinical reasoning tasks. They evaluated the type, number, and sequence of tasks the residents used. Ten residents participated in the study in 2013-2014. Across all three cases, the residents employed 14 clinical reasoning tasks. Nearly all coded tasks were associated with framing the encounter or diagnosis. The order in which residents used specific tasks varied. The average number of tasks used per case was as follows: Case 1, 4.4 (range 1-10); Case 2, 4.6 (range 1-6); and Case 3, 4.7 (range 1-7). The residents used some tasks repeatedly; the average number of task utterances was 11.6, 13.2, and 14.7 for, respectively, Case 1, 2, and 3. Results suggest that the use of clinical reasoning tasks occurs in a varied, not sequential, process. The authors provide suggestions for strengthening the framework to more fully encompass the spectrum of reasoning tasks that occur in residents' clinical encounters.

Electronic Medical Records and Same Day Patient Tracing Improves Clinic Efficiency and Adherence to Appointments in a Community Based HIV/AIDS Care Program, in Uganda

PubMed Central

Alamo, Stella T.; Wagner, Glenn J.; Sunday, Pamela; Wanyenze, Rhoda K.; Ouma, Joseph; Kamya, Moses; Colebunders, Robert; Wabwire-Mangen, Fred

2013-01-01

Patients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre-EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to follow-up (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency. PMID:21739285

Teaching for clinical reasoning - helping students make the conceptual links.

PubMed

McMillan, Wendy Jayne

2010-01-01

Dental educators complain that students struggle to apply what they have learnt theoretically in the clinical context. This paper is premised on the assumption that there is a relationship between conceptual thinking and clinical reasoning. The paper provides a theoretical framework for understanding the relationship between conceptual learning and clinical reasoning. A review of current literature is used to explain the way in which conceptual understanding influences clinical reasoning and the transfer of theoretical understandings to the clinical context. The paper argues that the connections made between concepts are what is significant about conceptual understanding. From this point of departure the paper describes teaching strategies that facilitate the kinds of learning opportunities that students need in order to develop conceptual understanding and to be able to transfer knowledge from theoretical to clinical contexts. Along with a variety of teaching strategies, the value of concept maps is discussed. The paper provides a framework for understanding the difficulties that students have in developing conceptual networks appropriate for later clinical reasoning. In explaining how students learn for clinical application, the paper provides a theoretical framework that can inform how dental educators facilitate the conceptual learning, and later clinical reasoning, of their students.

Using the e-Chasqui, web-based information system, to determine laboratory guidelines and data available to clinical staff.

PubMed

Blaya, Joaquin A; Yagui, Martin; Contreras, Carmen C; Palma, Betty; Shin, Sonya S; Yale, Gloria; Suarez, Carmen; Fraser, Hamish S F

2008-11-06

13% of all drug susceptibility tests (DSTs) performed at a public laboratory in Peru were duplicate. To determine reasons for duplicate requests an online survey was implemented in the e-Chasqui laboratory information system. Results showed that 59.6% of tests were ordered because clinical staff was unaware of ordering guidelines or of a previous result. This shows a benefit of using a web-based system and the lack of laboratory information available to clinical staff in Peru.

[Evidence-based aspects of clinical mastitis treatment].

PubMed

Mansion-de Vries, E M; Hoedemaker, M; Krömker, V

2015-01-01

Mastitis is one of the most common and expensive diseases in dairy cattle. The decision to treat clinical mastitis is usually made without any knowledge of the etiology, and can therefore only be evidence-based to a limited extent. Evidence-based medicine relies essentially on a combination of one's own clinical competence and scientific findings. In mastitis therapy, those insights depend mostly on pathogen-specific factors. Therefore, in evidence-based therapeutic decision making the pathogen identification should serve as a basis for the consideration of scientifically validated therapeutic concepts. The present paper considers evidence-based treatment of clinical mastitis based on a literature review. The authors conclude that an anti-inflammatory treatment using an NSAID should be conducted regardless of the pathogen. However, the choice of an antibiotic therapy depends on the mastitis causative pathogen, clinical symptoms and the animal itself. In principle, a local antibiotic treatment should be chosen for mild and moderate mastitis. It should be noted, that the benefit of an antibiotic therapy for coliform infections is questionable. With knowledge concerning the pathogen, it appears entirely reasonable to refrain from an antibiotic therapy. For severe (i.   e. feverish) mastitis, a parenteral antibiotic therapy should be selected. An extension of the antibiotic therapy beyond the manufacturer's information is only reasonable for streptococcal infections. It is important to make the decision on a prolonged antibiotic therapy only with the knowledge of the mastitis-causative pathogen. In terms of the therapy of a staphylococcus or streptococcus infection, a narrow-spectrum antibiotic from the penicillin family should be adopted when selecting the active agents.

Using the core curriculum on childhood trauma to strengthen clinical knowledge in evidence-based practitioners.

PubMed

Layne, Christopher M; Strand, Virginia; Popescu, Marciana; Kaplow, Julie B; Abramovitz, Robert; Stuber, Margaret; Amaya-Jackson, Lisa; Ross, Leslie; Pynoos, Robert S

2014-01-01

The high prevalence of trauma exposure in mental health service-seeking populations, combined with advances in evidence-based practice, competency-based training, common-elements research, and adult learning make this an opportune time to train the mental health workforce in trauma competencies. The Core Curriculum on Childhood Trauma (CCCT) utilizes a five-tiered conceptual framework (comprising Empirical Evidence, Core Trauma Concepts, Intervention Objectives, Practice Elements, and Skills), coupled with problem-based learning, to build foundational trauma knowledge and clinical reasoning skills. We present findings from three studies: Study 1 found that social work graduate students' participation in a CCCT course (N = 1,031) was linked to significant pre-post increases in self-reported confidence in applying core trauma concepts to their clinical work. Study 2 found significant pre-post increases in self-reported conceptual readiness (N = 576) and field readiness (N = 303) among social work graduate students participating in a "Gold Standard Plus" educational model that integrated classroom instruction in core trauma concepts, training in evidence-based trauma treatment (EBTT), and implementation of that EBTT in a supervised field placement. Students ranked the core concepts course as an equivalent or greater contributor to field readiness compared to standard EBTT training. Study 3 used qualitative methods to "distill" common elements (35 intervention objectives, 59 practice elements) from 26 manualized trauma interventions. The CCCT is a promising tool for educating "next-generation" evidence-based practitioners who possess competencies needed to implement modularized, individually tailored trauma interventions by strengthening clinical knowledge, clinical reasoning, and familiarity with common elements.

A platform for exploration into chaining of web services for clinical data transformation and reasoning

PubMed Central

Maldonado, José Alberto; Marcos, Mar; Fernández-Breis, Jesualdo Tomás; Parcero, Estíbaliz; Boscá, Diego; Legaz-García, María del Carmen; Martínez-Salvador, Begoña; Robles, Montserrat

2016-01-01

The heterogeneity of clinical data is a key problem in the sharing and reuse of Electronic Health Record (EHR) data. We approach this problem through the combined use of EHR standards and semantic web technologies, concretely by means of clinical data transformation applications that convert EHR data in proprietary format, first into clinical information models based on archetypes, and then into RDF/OWL extracts which can be used for automated reasoning. In this paper we describe a proof-of-concept platform to facilitate the (re)configuration of such clinical data transformation applications. The platform is built upon a number of web services dealing with transformations at different levels (such as normalization or abstraction), and relies on a collection of reusable mappings designed to solve specific transformation steps in a particular clinical domain. The platform has been used in the development of two different data transformation applications in the area of colorectal cancer. PMID:28269882

Assessing the ACGME Competencies in Psychiatry Training Programs

ERIC Educational Resources Information Center

Swick, Susan; Hall, Sarah; Beresin, Eugene

2006-01-01

In 2000, the Accreditation Council of Graduate Medical Education (ACGME) laid out a definition of competence that included six specific areas of focus: patient care (including clinical reasoning), medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The…

An official multi-society statement: the role of clinical research results in the practice of critical care medicine.

PubMed

Tonelli, Mark R; Curtis, J Randall; Guntupalli, Kalpalatha K; Rubenfeld, Gordon D; Arroliga, Alejandro C; Brochard, Laurent; Douglas, Ivor S; Gutterman, David D; Hall, Jesse R; Kavanagh, Brian P; Mancebo, Jordi; Misak, Cheryl J; Simpson, Steven Q; Slutsky, Arthur S; Suffredini, Anthony F; Thompson, B Taylor; Ware, Lorraine B; Wheeler, Arthur P; Levy, Mitchell M

2012-05-15

While the results of clinical research are clearly valuable in the care of critically ill patients, the limitations of such information and the role of other forms of medical knowledge for clinical decision making have not been carefully examined. The leadership of three large professional societies representing critical care practitioners convened a diverse group representing a wide variety of views regarding the role of clinical research results in clinical practice to develop a document to serve as a basis for agreement and a framework for ongoing discussion. Consensus was reached on several issues. While the results of rigorous clinical research are important in arriving at the best course of action for an individual critically ill patient, other forms of medical knowledge, including clinical experience and pathophysiologic reasoning, remain essential. No single source of knowledge is sufficient to guide clinical decisions, nor does one kind of knowledge always take precedence over others. Clinicians will find clinical research compelling for a variety of reasons that go beyond study design. While clinical practice guidelines and protocols based upon clinical research may improve care and decrease variability in practice, clinicians must be able to understand and articulate the rationale as to why a particular protocol or guideline is used or why an alternative approach is taken. Making this clinical reasoning explicit is necessary to understand practice variability. Understanding the strengths and weaknesses of different kinds of medical knowledge for clinical decision making and factors beyond study design that make clinical research compelling to clinicians can provide a framework for understanding the role of clinical research in practice.

Physiotherapy students' perceptions and experiences of clinical prediction rules.

PubMed

Knox, Grahame M; Snodgrass, Suzanne J; Stanton, Tasha R; Kelly, David H; Vicenzino, Bill; Wand, Benedict M; Rivett, Darren A

2017-09-01

Clinical reasoning can be difficult to teach to pre-professional physiotherapy students due to their lack of clinical experience. It may be that tools such as clinical prediction rules (CPRs) could aid the process, but there has been little investigation into their use in physiotherapy clinical education. This study aimed to determine the perceptions and experiences of physiotherapy students regarding CPRs, and whether they are learning about CPRs on clinical placement. Cross-sectional survey using a paper-based questionnaire. Final year pre-professional physiotherapy students (n=371, response rate 77%) from five universities across five states of Australia. Sixty percent of respondents had not heard of CPRs, and a further 19% had not clinically used CPRs. Only 21% reported using CPRs, and of these nearly three-quarters were rarely, if ever, learning about CPRs in the clinical setting. However most of those who used CPRs (78%) believed CPRs assisted in the development of clinical reasoning skills and none (0%) was opposed to the teaching of CPRs to students. The CPRs most commonly recognised and used by students were those for determining the need for an X-ray following injuries to the ankle and foot (67%), and for identifying deep venous thrombosis (63%). The large majority of students in this sample knew little, if anything, about CPRs and few had learned about, experienced or practiced them on clinical placement. However, students who were aware of CPRs found them helpful for their clinical reasoning and were in favour of learning more about them. Copyright © 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study.

PubMed

Barken, Tina Lien; Thygesen, Elin; Söderhamn, Ulrika

2017-12-28

Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated. In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis. When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process. In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses' reasoning process. Nurses' reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses' reasoning process.

Deepening the quality of clinical reasoning and decision-making in rural hospital nursing practice.

PubMed

Sedgwick, M G; Grigg, L; Dersch, S

2014-01-01

Rural acute care nursing requires an extensive breadth and depth of knowledge as well as the ability to quickly reason through problems in order to make sound clinical decisions. This reasoning often occurs within an environment that has minimal medical or ancillary support. Registered nurses (RN) new to rural nursing, and employers, have raised concerns about patient safety while new nurses make the transition into rural practice. In addition, feeling unprepared for the rigors of rural hospital nursing practice is a central issue influencing RN recruitment and retention. Understanding how rural RNs reason is a key element for identifying professional development needs and may support recruitment and retention of skilled rural nurses. The purpose of this study was to explore how rural RNs reason through clinical problems as well as to assess the quality of such reasoning. This study used a non-traditional approach for data collection. Fifteen rural acute care nurses with varying years of experience working in southern Alberta, Canada, were observed while they provided care to patients of varying acuity within a simulated rural setting. Following the simulation, semi-structured interviews were conducted using a substantive approach to critical thinking. Findings revealed that the ability to engage in deep clinical reasoning varied considerably among participants despite being given the same information under the same circumstances. Furthermore, the number of years of experience did not seem to be directly linked to the ability to engage in sound clinical reasoning. Novice nurses, however, did rely heavily on others in their decision making in order to ensure they were making the right decision. Hence, their relationships with other staff members influenced their ability to engage in clinical reasoning and decision making. In situations where the patient's condition was deteriorating quickly, regardless of years of experience, all of the participants depended on their colleagues when making decisions and reasoning throughout the simulation. Deep clinical reasoning and decision making is a function of reflection and self-correction that requires a critical self-awareness and is more about how nurses think than what they think. The degree of sophistication in reasoning of experts and novices is at times equivalent in that the reasoning of experts and novices can be somewhat limited and focused primarily on human physicality and less on conceptual knowledge. To become proficient in clinical reasoning, practice is necessary. The study supports the accumulating evidence that using clinical simulation and reflective interviewing that emphasize how clinical decisions are made enhances reasoning skills and confidence.

Critical thinking versus clinical reasoning versus clinical judgment: differential diagnosis.

PubMed

Victor-Chmil, Joyce

2013-01-01

Concepts of critical thinking, clinical reasoning, and clinical judgment are often used interchangeably. However, they are not one and the same, and understanding subtle difference among them is important. Following a review of the literature for definitions and uses of the terms, the author provides a summary focused on similarities and differences in the processes of critical thinking, clinical reasoning, and clinical judgment and notes suggested methods of measuring each.

Grappling with the Future Use of Big Data for Translational Medicine and Clinical Care.

PubMed

Murphy, S; Castro, V; Mandl, K

2017-08-01

Objectives: Although patients may have a wealth of imaging, genomic, monitoring, and personal device data, it has yet to be fully integrated into clinical care. Methods: We identify three reasons for the lack of integration. The first is that "Big Data" is poorly managed by most Electronic Medical Record Systems (EMRS). The data is mostly available on "cloud-native" platforms that are outside the scope of most EMRs, and even checking if such data is available on a patient often must be done outside the EMRS. The second reason is that extracting features from the Big Data that are relevant to healthcare often requires complex machine learning algorithms, such as determining if a genomic variant is protein-altering. The third reason is that applications that present Big Data need to be modified constantly to reflect the current state of knowledge, such as instructing when to order a new set of genomic tests. In some cases, applications need to be updated nightly. Results: A new architecture for EMRS is evolving which could unite Big Data, machine learning, and clinical care through a microservice-based architecture which can host applications focused on quite specific aspects of clinical care, such as managing cancer immunotherapy. Conclusion: Informatics innovation, medical research, and clinical care go hand in hand as we look to infuse science-based practice into healthcare. Innovative methods will lead to a new ecosystem of applications (Apps) interacting with healthcare providers to fulfill a promise that is still to be determined. Georg Thieme Verlag KG Stuttgart.

Chasing the Mirage: a grounded theory of the clinical reasoning processes that Registered Nurses use to recognize delirium.

PubMed

El Hussein, Mohamed; Hirst, Sandra

2016-02-01

The aim of this study was to construct a grounded theory that explains the clinical reasoning processes that registered nurses use to recognize delirium in older adults in acute care hospitals. Delirium is under-recognized in acute hospital settings, this may stem from underdeveloped clinical reasoning processes. Little is known about registered nurses' (RNs) clinical reasoning processes in complex situations such as delirium recognition. A grounded theory approach was used to analyse interview data about the clinical reasoning processes of RNs in acute hospital settings. Seventeen RNs were recruited. Concurrent data collection and comparative analysis and theoretical sampling were conducted in 2013-2014. The core category to emerge from the data was 'chasing the mirage', which describes RNs' clinical reasoning processes to recognize delirium during their interaction with older adults. Understanding the reasoning that contributes to delirium under-recognition provides a strategy by which, this problem can be brought to the forefront of RNs' awareness and intervention. Delirium recognition will contribute to quality care for older adults. © 2015 John Wiley & Sons Ltd.

The use of intuitive and analytic reasoning styles by patients with persecutory delusions.

PubMed

Freeman, Daniel; Lister, Rachel; Evans, Nicole

2014-12-01

A previous study has shown an association of paranoid thinking with a reliance on rapid intuitive ('experiential') reasoning and less use of slower effortful analytic ('rational') reasoning. The objectives of the new study were to replicate the test of paranoia and reasoning styles in a large general population sample and to assess the use of these reasoning styles in patients with persecutory delusions. 30 Patients with persecutory delusions in the context of a non-affective psychotic disorder and 1000 non-clinical individuals completed self-report assessments of paranoia and reasoning styles. The patients with delusions reported lower levels of both experiential and analytic reasoning than the non-clinical individuals (effect sizes small to moderate). Both self-rated ability and engagement with the reasoning styles were lower in the clinical group. Within the non-clinical group, greater levels of paranoia were associated with lower levels of analytic reasoning, but there was no association with experiential reasoning. The study is cross-sectional and cannot determine whether the reasoning styles contribute to the occurrence of paranoia. It also cannot be determined whether the patient group's lower reasoning scores are specifically associated with the delusions. Clinical paranoia is associated with less reported use of analytic and experiential reasoning. This may reflect patients with current delusions being unconfident in their reasoning abilities or less aware of decision-making processes and hence less able to re-evaluate fearful cognitions. The dual process theory of reasoning may provide a helpful framework in which to discuss with patients decision-making styles. Copyright © 2014 Elsevier Ltd. All rights reserved.

Clinical physiology grand rounds.

PubMed

Richards, Jeremy; Schwartzstein, Richard; Irish, Julie; Almeida, Jacqueline; Roberts, David

2013-04-01

Clinical Physiology Grand Rounds (CPGR) is an interactive, case-based conference for medical students designed to: (1) integrate preclinical and clinical learning; (2) promote inductive clinical reasoning; and (3) emphasise students as peer teachers. CPGR specifically encourages mixed learning level student interactions and emphasises the use of concept mapping. We describe the theoretical basis and logistical considerations for an interactive, integrative, mixed-learner environment such as CPGR. In addition, we report qualitative data regarding students' attitudes towards and perceptions of CPGR. Medical students from first to fourth year participate in a monthly, interactive conference. The CPGR was designed to bridge gaps and reinforce linkages between basic science and clinical concepts, and to incorporate interactive vertical integration between preclinical and clinical students. Medical education and content experts use Socratic, interactive teaching methods to develop real-time concept maps to emphasise the presence and importance of linkages across curricula. Student focus groups were held to assess attitudes towards and perceptions of the mixed-learner environment and concept maps in CPGR. Qualitative analyses of focus group transcripts were performed to develop themes and codes describing the students' impressions of CPGR. CPGR is a case-based, interactive conference designed to help students gain an increased appreciation of linkages between basic science and clinical medicine concepts, and an increased awareness of clinical reasoning thought processes. Success is dependent upon explicit attention being given to goals for students' integrated learning. © Blackwell Publishing Ltd 2013.

Barriers and benefits associated with nurses information seeking related to patient education needs on clinical nursing units.

PubMed

Jones, Josette; Schilling, Katherine; Pesut, Daniel

2011-01-01

The purpose of this study was to answer the following two questions: What are clinical nurses' rationales for their approaches to finding patient educational materials on the web? What are perceived barriers and benefits associated with the use of web-based information resources for patient education in the context of nursing clinical practice?Over 179 individual data units were analyzed to understand clinical nurses' rationales for their approaches to find patient educational materials on the web. Rationales were defined as those underlying catalysts or activators leading to an information need. Analyses found that the primary reasons why clinical nurses conducted web-based information searches included direct patient requests ( 9 requests), colleague requests (6 requests), building patient materials collections (4), patients' family requests (3), routine teaching (1), personal development (1), or staff development (1). From these data, four broad themes emerged: professional reasons, personal reasons, technology reasons, and organization reasons for selecting information resources. Content analysis identified 306 individual data units representing either 'benefits' (178 units) or 'barriers' (128) to the nurses' use of web resources for on-unit patient care. Inter-rater reliability was assessed and found to be excellent (r = 0.943 to 0.961). The primary themes that emerged as barriers to the used of web-based resources included: 1) time requirements to perform a search, 2) nurses' experience and knowledge about the resources or required technology, 3) specific characteristics of individuals electronic information resources, and 4) organizational procedures and policies. Three primary themes that represented the benefits of using web-based resources were also identified: 1) past experiences and knowledge of a specific resource or the required technologies, 2) availability and accessibility on the unit, and 3) specific characteristics of individual information tool. In many cases, nurses commented on specific characteristics or features of favorite information resources. Favorite sites included a variety or reputable health care organizations that displayed context in text, audio, and/or video. In addition such sites were described as easy-to read and provided content related to patient-focused information or specific content such as toll free telephone contact numbers.Information searching is the interaction between and among information users and computer-based information systems. Information seeking is becoming an important part of the knowledge work of nurses. Information seeking and searching intersects with the field of human computer interaction (HCI), which focuses on all aspects of human, and computer interactions. Users of an information system are understood as "actors" in situations, with a set of skills and shared practices based on work experiences with others. Designing better tools and developing information searching strategies that support, extend, and transform practices, begins by asking: Who are the users? What are the tasks? What is the interplay between the technology and the organization of the task? This study contributes fundamental data and information about the rationales nurses use in information seeking tasks. In addition it provides empirical evidences regarding barriers and benefits of information seeking in the context of patient education needs in inpatient clinical settings.

Increasing Reasoning Awareness: Video Analysis of Students' Two-Party Virtual Patient Interactions.

PubMed

Edelbring, Samuel; Parodis, Ioannis; Lundberg, Ingrid E

2018-02-27

Collaborative reasoning occurs in clinical practice but is rarely developed during education. The computerized virtual patient (VP) cases allow for a stepwise exploration of cases and thus stimulate active learning. Peer settings during VP sessions are believed to have benefits in terms of reasoning but have received scant attention in the literature. The objective of this study was to thoroughly investigate interactions during medical students' clinical reasoning in two-party VP settings. An in-depth exploration of students' interactions in dyad settings of VP sessions was performed. For this purpose, two prerecorded VP sessions lasting 1 hour each were observed, transcribed in full, and analyzed. The transcriptions were analyzed using thematic analysis, and short clips from the videos were selected for subsequent analysis in relation to clinical reasoning and clinical aspects. Four categories of interactions were identified: (1) task-related dialogue, in which students negotiated a shared understanding of the task and strategies for information gathering; (2) case-related insights and perspectives were gained, and the students consolidated and applied preexisting biomedical knowledge into a clinical setting; (3) clinical reasoning interactions were made explicit. In these, hypotheses were followed up and clinical examples were used. The researchers observed interactions not only between students and the VP but also (4) interactions with other resources, such as textbooks. The interactions are discussed in relation to theories of clinical reasoning and peer learning. The dyad VP setting is conducive to activities that promote analytic clinical reasoning. In this setting, components such as peer interaction, access to different resources, and reduced time constraints provided a productive situation in which the students pursued different lines of reasoning. ©Samuel Edelbring, Ioannis Parodis, Ingrid E Lundberg. Originally published in JMIR Medical Education (http://mededu.jmir.org), 27.02.2018.

Increasing Reasoning Awareness: Video Analysis of Students’ Two-Party Virtual Patient Interactions

PubMed Central

Parodis, Ioannis; Lundberg, Ingrid E

2018-01-01

Background Collaborative reasoning occurs in clinical practice but is rarely developed during education. The computerized virtual patient (VP) cases allow for a stepwise exploration of cases and thus stimulate active learning. Peer settings during VP sessions are believed to have benefits in terms of reasoning but have received scant attention in the literature. Objective The objective of this study was to thoroughly investigate interactions during medical students’ clinical reasoning in two-party VP settings. Methods An in-depth exploration of students’ interactions in dyad settings of VP sessions was performed. For this purpose, two prerecorded VP sessions lasting 1 hour each were observed, transcribed in full, and analyzed. The transcriptions were analyzed using thematic analysis, and short clips from the videos were selected for subsequent analysis in relation to clinical reasoning and clinical aspects. Results Four categories of interactions were identified: (1) task-related dialogue, in which students negotiated a shared understanding of the task and strategies for information gathering; (2) case-related insights and perspectives were gained, and the students consolidated and applied preexisting biomedical knowledge into a clinical setting; (3) clinical reasoning interactions were made explicit. In these, hypotheses were followed up and clinical examples were used. The researchers observed interactions not only between students and the VP but also (4) interactions with other resources, such as textbooks. The interactions are discussed in relation to theories of clinical reasoning and peer learning. Conclusions The dyad VP setting is conducive to activities that promote analytic clinical reasoning. In this setting, components such as peer interaction, access to different resources, and reduced time constraints provided a productive situation in which the students pursued different lines of reasoning. PMID:29487043

An object-oriented, knowledge-based system for cardiovascular rehabilitation--phase II.

PubMed Central

Ryder, R. M.; Inamdar, B.

1995-01-01

The Heart Monitor is an object-oriented, knowledge-based system designed to support the clinical activities of cardiovascular (CV) rehabilitation. The original concept was developed as part of graduate research completed in 1992. This paper describes the second generation system which is being implemented in collaboration with a local heart rehabilitation program. The PC UNIX-based system supports an extensive patient database organized by clinical areas. In addition, a knowledge base is employed to monitor patient status. Rule-based automated reasoning is employed to assess risk factors contraindicative to exercise therapy and to monitor administrative and statutory requirements. PMID:8563285

Clinical Correlations as a Tool in Basic Science Medical Education

PubMed Central

Klement, Brenda J.; Paulsen, Douglas F.; Wineski, Lawrence E.

2016-01-01

Clinical correlations are tools to assist students in associating basic science concepts with a medical application or disease. There are many forms of clinical correlations and many ways to use them in the classroom. Five types of clinical correlations that may be embedded within basic science courses have been identified and described. (1) Correlated examples consist of superficial clinical information or stories accompanying basic science concepts to make the information more interesting and relevant. (2) Interactive learning and demonstrations provide hands-on experiences or the demonstration of a clinical topic. (3) Specialized workshops have an application-based focus, are more specialized than typical laboratory sessions, and range in complexity from basic to advanced. (4) Small-group activities require groups of students, guided by faculty, to solve simple problems that relate basic science information to clinical topics. (5) Course-centered problem solving is a more advanced correlation activity than the others and focuses on recognition and treatment of clinical problems to promote clinical reasoning skills. Diverse teaching activities are used in basic science medical education, and those that include clinical relevance promote interest, communication, and collaboration, enhance knowledge retention, and help develop clinical reasoning skills. PMID:29349328

System Architecture for Temporal Information Extraction, Representation and Reasoning in Clinical Narrative Reports

PubMed Central

Zhou, Li; Friedman, Carol; Parsons, Simon; Hripcsak, George

2005-01-01

Exploring temporal information in narrative Electronic Medical Records (EMRs) is essential and challenging. We propose an architecture for an integrated approach to process temporal information in clinical narrative reports. The goal is to initiate and build a foundation that supports applications which assist healthcare practice and research by including the ability to determine the time of clinical events (e.g., past vs. present). Key components include: (1) a temporal constraint structure for temporal expressions and the development of an associated tagger; (2) a Natural Language Processing (NLP) system for encoding and extracting medical events and associating them with formalized temporal data; (3) a post-processor, with a knowledge-based subsystem to help discover implicit information, that resolves temporal expressions and deals with issues such as granularity and vagueness; and (4) a reasoning mechanism which models clinical reports as Simple Temporal Problems (STPs). PMID:16779164

Detecting fast, online reasoning processes in clinical decision making.

PubMed

Flores, Amanda; Cobos, Pedro L; López, Francisco J; Godoy, Antonio

2014-06-01

In an experiment that used the inconsistency paradigm, experienced clinical psychologists and psychology students performed a reading task using clinical reports and a diagnostic judgment task. The clinical reports provided information about the symptoms of hypothetical clients who had been previously diagnosed with a specific mental disorder. Reading times of inconsistent target sentences were slower than those of control sentences, demonstrating an inconsistency effect. The results also showed that experienced clinicians gave different weights to different symptoms according to their relevance when fluently reading the clinical reports provided, despite the fact that all the symptoms were of equal diagnostic value according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The diagnostic judgment task yielded a similar pattern of results. In contrast to previous findings, the results of the reading task may be taken as direct evidence of the intervention of reasoning processes that occur very early, rapidly, and online. We suggest that these processes are based on the representation of mental disorders and that these representations are particularly suited to fast retrieval from memory and to making inferences. They may also be related to the clinicians' causal reasoning. The implications of these results for clinician training are also discussed.

Why aren’t they happy? An analysis of end-user satisfaction with Electronic health records

PubMed Central

Unni, Prasad; Staes, Catherine; Weeks, Howard; Kramer, Heidi; Borbolla, Damion; Slager, Stacey; Taft, Teresa; Chidambaram, Valliammai; Weir, Charlene

2016-01-01

Introduction. Implementations of electronic health records (EHR) have been met with mixed outcome reviews. Complaints about these systems have led to many attempts to have useful measures of end-user satisfaction. However, most user satisfaction assessments do not focus on high-level reasoning, despite the complaints of many physicians. Our study attempts to identify some of these determinants. Method. We developed a user satisfaction survey instrument, based on pre-identified and important clinical and non-clinical clinician tasks. We surveyed a sample of in-patient physicians and focused on using exploratory factor analyses to identify underlying high-level cognitive tasks. We used the results to create unique, orthogonal variables representative of latent structure predictive of user satisfaction. Results. Our findings identified 3 latent high-level tasks that were associated with end-user satisfaction: a) High- level clinical reasoning b) Communicate/coordinate care and c) Follow the rules/compliance. Conclusion: We were able to successfully identify latent variables associated with satisfaction. Identification of communicability and high-level clinical reasoning as important factors determining user satisfaction can lead to development and design of more usable electronic health records with higher user satisfaction. PMID:28269962

An Embodied and Intersubjective Practice of Occupational Therapy.

PubMed

Arntzen, Cathrine

2017-08-01

The literature on clinical reasoning tends to ignore the context and the interaction between patient and therapist. This article outlines a theoretical foundation for an extended mode of clinical reasoning in occupational therapy. Cognitive theories of human action, as well as narrative and instrumental approaches, provide an insufficient picture of the nature of clinical reasoning in occupational therapy practice. An embodied intersubjective clinical reasoning can function as an adjunct to traditional clinical reasoning in occupational therapy practice and is discussed through the concepts of the ambiguous body, incorporation of things, and the process of shared meaning-making. This mode of reasoning can help occupational therapy practitioners to be aware of how they influence the patient's perception of body, self, and world. It can promote a better understanding of details in embodied performances and in the co-construction of meaning, positively influencing occupation, participation, and health.

Knowing How and Knowing Why: Testing the Effect of Instruction Designed for Cognitive Integration on Procedural Skills Transfer

ERIC Educational Resources Information Center

Cheung, Jeffrey J. H.; Kulasegaram, Kulamakan M.; Woods, Nicole N.; Moulton, Carol-anne; Ringsted, Charlotte V.; Brydges, Ryan

2018-01-01

Transfer is a desired outcome of simulation-based training, yet evidence for how instructional design features promote transfer is lacking. In clinical reasoning, transfer is improved when trainees experience instruction integrating basic science explanations with clinical signs and symptoms. To test whether integrated instruction has similar…

Tracking the footsteps: a constructivist grounded theory of the clinical reasoning processes that registered nurses use to recognise delirium.

PubMed

El Hussein, Mohamed; Hirst, Sandra

2016-02-01

To construct a grounded theory that explains the clinical reasoning processes that registered nurses use to recognise delirium while caring for older adults in acute care settings. Delirium is often under-recognised in acute care settings; this may stem from underdeveloped clinical reasoning processes. Little is known about registered nurses' clinical reasoning processes in complex situations such as delirium recognition. Seventeen registered nurses working in acute care settings were interviewed. Concurrent data collection and analysis, constant comparative analysis and theoretical sampling were conducted in 2013-2014. A grounded theory approach was used to analyse interview data about the clinical reasoning processes of registered nurse in acute hospital settings. The core category that emerged from data was 'Tracking the footsteps'. This refers to the common clinical reasoning processes that registered nurses in this study used to recognise delirium in older adults in acute care settings. It depicted the process of continuously trying to catch the state of delirium in older adults. Understanding the clinical reasoning processes that contribute to delirium under-recognition provides a strategy by which this problem can be brought to the forefront of awareness and intervention by registered nurses. Registered nurses could draw from the various processes identified in this research to develop their clinical reasoning practice to enhance their effective assessment strategies. Delirium recognition by registered nurses will contribute to quality care to older adults. © 2016 John Wiley & Sons Ltd.

Patterns of Clinical Reasoning in Physical Therapist Students.

PubMed

Gilliland, Sarah; Wainwright, Susan Flannery

2017-05-01

Clinical reasoning is a complex, nonlinear problem-solving process that is influenced by models of practice. The development of physical therapists' clinical reasoning abilities is a crucial yet underresearched aspect of entry-level (professional) physical therapist education. The purpose of this qualitative study was to examine the types of clinical reasoning strategies physical therapist students engage in during a patient encounter. A qualitative descriptive case study design involving within and across case analysis was used. Eight second-year, professional physical therapist students from 2 different programs completed an evaluation and initial intervention for a standardized patient followed by a retrospective think-aloud interview to explicate their reasoning processes. Participants' clinical reasoning strategies were examined using a 2-stage qualitative method of thematic analysis. Participants demonstrated consistent signs of development of physical therapy-specific reasoning processes, yet varied in their approach to the case and use of reflection. Participants who gave greater attention to patient education and empowerment also demonstrated greater use of reflection-in-action during the patient encounter. One negative case illustrates the variability in the rate at which students may develop these abilities. Participants demonstrated development toward physical therapist--specific clinical reasoning, yet demonstrated qualitatively different approaches to the patient encounter. Multiple factors, including the use of reflection-in-action, may enable students to develop greater flexibility in their reasoning processes. © 2017 American Physical Therapy Association

Evaluation of audit-based performance measures for dental care plans.

PubMed

Bader, J D; Shugars, D A; White, B A; Rindal, D B

1999-01-01

Although a set of clinical performance measures, i.e., a report card for dental plans, has been designed for use with administrative data, most plans do not have administrative data systems containing the data needed to calculate the measures. Therefore, we evaluated the use of a set of proxy clinical performance measures calculated from data obtained through chart audits. Chart audits were conducted in seven dental programs--three public health clinics, two dental health maintenance organizations (DHMO), and two preferred provider organizations (PPO). In all instances audits were completed by clinical staff who had been trained using telephone consultation and a self-instructional audit manual. The performance measures were calculated for the seven programs, audit reliability was assessed in four programs, and for one program the audit-based proxy measures were compared to the measures calculated using administrative data. The audit-based measures were sensitive to known differences in program performance. The chart audit procedures yielded reasonably reliable data. However, missing data in patient charts rendered the calculation of some measures problematic--namely, caries and periodontal disease assessment and experience. Agreement between administrative and audit-based measures was good for most, but not all, measures in one program. The audit-based proxy measures represent a complex but feasible approach to the calculation of performance measures for those programs lacking robust administrative data systems. However, until charts contain more complete diagnostic information (i.e., periodontal charting and diagnostic codes or reason-for-treatment codes), accurate determination of these aspects of clinical performance will be difficult.

Chapter 1: Biomedical knowledge integration.

PubMed

Payne, Philip R O

2012-01-01

The modern biomedical research and healthcare delivery domains have seen an unparalleled increase in the rate of innovation and novel technologies over the past several decades. Catalyzed by paradigm-shifting public and private programs focusing upon the formation and delivery of genomic and personalized medicine, the need for high-throughput and integrative approaches to the collection, management, and analysis of heterogeneous data sets has become imperative. This need is particularly pressing in the translational bioinformatics domain, where many fundamental research questions require the integration of large scale, multi-dimensional clinical phenotype and bio-molecular data sets. Modern biomedical informatics theory and practice has demonstrated the distinct benefits associated with the use of knowledge-based systems in such contexts. A knowledge-based system can be defined as an intelligent agent that employs a computationally tractable knowledge base or repository in order to reason upon data in a targeted domain and reproduce expert performance relative to such reasoning operations. The ultimate goal of the design and use of such agents is to increase the reproducibility, scalability, and accessibility of complex reasoning tasks. Examples of the application of knowledge-based systems in biomedicine span a broad spectrum, from the execution of clinical decision support, to epidemiologic surveillance of public data sets for the purposes of detecting emerging infectious diseases, to the discovery of novel hypotheses in large-scale research data sets. In this chapter, we will review the basic theoretical frameworks that define core knowledge types and reasoning operations with particular emphasis on the applicability of such conceptual models within the biomedical domain, and then go on to introduce a number of prototypical data integration requirements and patterns relevant to the conduct of translational bioinformatics that can be addressed via the design and use of knowledge-based systems.

Chapter 1: Biomedical Knowledge Integration

PubMed Central

Payne, Philip R. O.

2012-01-01

The modern biomedical research and healthcare delivery domains have seen an unparalleled increase in the rate of innovation and novel technologies over the past several decades. Catalyzed by paradigm-shifting public and private programs focusing upon the formation and delivery of genomic and personalized medicine, the need for high-throughput and integrative approaches to the collection, management, and analysis of heterogeneous data sets has become imperative. This need is particularly pressing in the translational bioinformatics domain, where many fundamental research questions require the integration of large scale, multi-dimensional clinical phenotype and bio-molecular data sets. Modern biomedical informatics theory and practice has demonstrated the distinct benefits associated with the use of knowledge-based systems in such contexts. A knowledge-based system can be defined as an intelligent agent that employs a computationally tractable knowledge base or repository in order to reason upon data in a targeted domain and reproduce expert performance relative to such reasoning operations. The ultimate goal of the design and use of such agents is to increase the reproducibility, scalability, and accessibility of complex reasoning tasks. Examples of the application of knowledge-based systems in biomedicine span a broad spectrum, from the execution of clinical decision support, to epidemiologic surveillance of public data sets for the purposes of detecting emerging infectious diseases, to the discovery of novel hypotheses in large-scale research data sets. In this chapter, we will review the basic theoretical frameworks that define core knowledge types and reasoning operations with particular emphasis on the applicability of such conceptual models within the biomedical domain, and then go on to introduce a number of prototypical data integration requirements and patterns relevant to the conduct of translational bioinformatics that can be addressed via the design and use of knowledge-based systems. PMID:23300416

Clinical group supervision for integrating ethical reasoning: Views from students and supervisors.

PubMed

Blomberg, Karin; Bisholt, Birgitta

2016-11-01

Clinical group supervision has existed for over 20 years in nursing. However, there is a lack of studies about the role of supervision in nursing students' education and especially the focus on ethical reasoning. The aim of this study was to explore and describe nursing students' ethical reasoning and their supervisors' experiences related to participation in clinical group supervision. The study is a qualitative interview study with interpretative description as an analysis approach. A total of 17 interviews were conducted with nursing students (n = 12) who had participated in clinical group supervision in their first year of nursing education, and with their supervisors (n = 5). The study was based on the ethical principles outlined in the Declaration of Helsinki, and permission was obtained from the Regional Ethical Review Board in Sweden. The analysis revealed that both the form and content of clinical group supervision stimulated reflection and discussion of handling of situations with ethical aspects. Unethical situations were identified, and the process uncovered underlying caring actions. Clinical group supervision is a model that can be used in nursing education to train ethical reflection and to develop an ethical competence among nursing students. Outcomes from the model could also improve nursing education itself, as well as healthcare organizations, in terms of reducing moral blindness and unethical nursing practice. © The Author(s) 2015.

Description and student self-evaluation of a pilot integrated small group learning and simulation programme for medical students in the first clinical year.

PubMed

Levinson, Michele; Kelly, Diane; Zahariou, Krisoula; Johnson, Matthew; Jackman, Christine; Mackenzie, Sara

2017-02-01

Contemporary education for medical students should be student-centred, integrated and contextualised. Small group learning promotes clinical reasoning and skills for lifelong learning. Simulation can provide experiential learning in a safe and controlled environment. We developed a weekly integrated problem-based learning and simulation programme (IPS) over two semesters in the first clinical year to augment clinical placement experience and contextualise theory into work-relevant practice. To evaluate the new programme at Kirkpatrick level 1. An anonymous survey of participating students. The programme was well liked. Students found the programme relevant and that they had a better understanding of patient safety and the assessment of the deteriorating patient. They felt it contributed to integration of theory and practice, clinical reasoning and the acquisition of non-technical skills, particularly affective and communication elements. This IPS programme in the first clinical year can deliver a student-centred curriculum to complement clinical placement that delivers the important requirements of contemporary medical student education. © 2016 Royal Australasian College of Physicians.

Case-based reasoning using electronic health records efficiently identifies eligible patients for clinical trials

PubMed Central

Miotto, Riccardo

2015-01-01

Objective To develop a cost-effective, case-based reasoning framework for clinical research eligibility screening by only reusing the electronic health records (EHRs) of minimal enrolled participants to represent the target patient for each trial under consideration. Materials and Methods The EHR data—specifically diagnosis, medications, laboratory results, and clinical notes—of known clinical trial participants were aggregated to profile the “target patient” for a trial, which was used to discover new eligible patients for that trial. The EHR data of unseen patients were matched to this “target patient” to determine their relevance to the trial; the higher the relevance, the more likely the patient was eligible. Relevance scores were a weighted linear combination of cosine similarities computed over individual EHR data types. For evaluation, we identified 262 participants of 13 diversified clinical trials conducted at Columbia University as our gold standard. We ran a 2-fold cross validation with half of the participants used for training and the other half used for testing along with other 30 000 patients selected at random from our clinical database. We performed binary classification and ranking experiments. Results The overall area under the ROC curve for classification was 0.95, enabling the highlight of eligible patients with good precision. Ranking showed satisfactory results especially at the top of the recommended list, with each trial having at least one eligible patient in the top five positions. Conclusions This relevance-based method can potentially be used to identify eligible patients for clinical trials by processing patient EHR data alone without parsing free-text eligibility criteria, and shows promise of efficient “case-based reasoning” modeled only on minimal trial participants. PMID:25769682

Parent Refusal of Topical Fluoride for Their Children: Clinical Strategies and Future Research Priorities to Improve Evidence-Based Pediatric Dental Practice.

PubMed

Chi, Donald L

2017-07-01

A growing number of parents are refusing topical fluoride for their children during preventive dental and medical visits. This nascent clinical and public health problem warrants attention from dental professionals and the scientific community. Clinical and community-based strategies are available to improve fluoride-related communications with parents and the public. In terms of future research priorities, there is a need to develop screening tools to identify parents who are likely to refuse topical fluoride and diagnostic instruments to uncover the reasons for topical fluoride refusal. This knowledge will lead to evidence-based strategies that can be widely disseminated into clinical practice. Copyright © 2017 Elsevier Inc. All rights reserved.

Problem-Based Learning and Learning Approach: Is There a Relationship?

ERIC Educational Resources Information Center

Groves, Michele

2005-01-01

Aim: To assess the influence of a graduate-entry PBL (problem-based learning) curriculum on individual learning style; and to investigate the relationship between learning style, academic achievement and clinical reasoning skill. Method: Subjects were first-year medical students completed the Study Process Questionnaire at the commencement, and…

The Pursuit of Understanding in Clinical Reasoning.

ERIC Educational Resources Information Center

Feltovich, Paul J.; Patel, Vimla L.

Trends in emphases in the study of clinical reasoning are examined, with attention to three major branches of research: problem-solving, knowledge engineering, and propositional analysis. There has been a general progression from a focus on the generic form of clinical reasoning to an emphasis on medical content that supports the reasoning…

The effect of short-term workshop on improving clinical reasoning skill of medical students

PubMed Central

Yousefichaijan, Parsa; Jafari, Farshad; Kahbazi, Manijeh; Rafiei, Mohammad; Pakniyat, AbdolGhader

2016-01-01

Background: Clinical reasoning process leads clinician to get purposeful steps from signs and symptoms toward diagnosis and treatment. This research intends to investigate the effect of teaching clinical reasoning on problem-solving skills of medical students. Methods: This research is a semi-experimental study. Nineteen Medical student of the pediatric ward as case group participated in a two-day workshop for training clinical reasoning. Before the workshop, they filled out Diagnostic Thinking Inventory (DTI) questionnaires. Fifteen days after the workshop the DTI questionnaire completed and "key feature" (KF) test and "clinical reasoning problem" (CRP) test was held. 23 Medical student as the control group, without passing the clinical reasoning workshop DTI questionnaire completed, and KF test and CRP test was held. Results: The average score of the DTI questionnaire in the control group was 162.04 and in the case group before the workshop was 153.26 and after the workshop was 181.68. Compare the average score of the DTI questionnaire before and after the workshop there is a significant difference. The difference between average KF test scores in the control and the case group was not significant but between average CRP test scores was significant. Conclusion: Clinical reasoning workshop is effectiveness in promoting problem-solving skills of students. PMID:27579286

The effect of short-term workshop on improving clinical reasoning skill of medical students.

PubMed

Yousefichaijan, Parsa; Jafari, Farshad; Kahbazi, Manijeh; Rafiei, Mohammad; Pakniyat, AbdolGhader

2016-01-01

Clinical reasoning process leads clinician to get purposeful steps from signs and symptoms toward diagnosis and treatment. This research intends to investigate the effect of teaching clinical reasoning on problem-solving skills of medical students. This research is a semi-experimental study. Nineteen Medical student of the pediatric ward as case group participated in a two-day workshop for training clinical reasoning. Before the workshop, they filled out Diagnostic Thinking Inventory (DTI) questionnaires. Fifteen days after the workshop the DTI questionnaire completed and "key feature" (KF) test and "clinical reasoning problem" (CRP) test was held. 23 Medical student as the control group, without passing the clinical reasoning workshop DTI questionnaire completed, and KF test and CRP test was held. The average score of the DTI questionnaire in the control group was 162.04 and in the case group before the workshop was 153.26 and after the workshop was 181.68. Compare the average score of the DTI questionnaire before and after the workshop there is a significant difference. The difference between average KF test scores in the control and the case group was not significant but between average CRP test scores was significant. Clinical reasoning workshop is effectiveness in promoting problem-solving skills of students.

Clinical Reasoning in Massage Therapy

PubMed Central

LeMoon, Kim

2008-01-01

Background: Clinical reasoning has long been a valuable tool for health care practitioners, but it has been under-researched in the field of massage therapy. Case reports have been a useful method for exploring the clinical reasoning process in various fields of manual therapy and can provide a model for similar research in the field of massage therapy. A diagnostically challenging case concerning a client with low back pain serves as a guideline for examining the clinical reasoning process of a massage therapist. Methods: A two-part methodology was employed: Client profileReflective inquiry The inquiry included questions pertaining to beliefs about health problems; beliefs about the mechanisms of pain; medical conditions that could explain the client’s symptoms; knowledge of the client’s anatomy, assessment, and treatment choices; observations made during treatment; extent of experience in treating similar problems; and ability to recognize clinical patterns. Results: The clinical reasoning process of a massage therapist contributed to a differential diagnosis, which provided an explanation for the client’s symptoms and led to a satisfactory treatment resolution. Conclusion: The present report serves as an example of the value of clinical reasoning in the field of massage therapy, and the need for expanded research into its methods and applications. The results of such research could be beneficial in teaching the clinical reasoning process at both the introductory and the advanced levels of massage therapy education. PMID:21589814

[Exploratory study of clinical reasoning in nursing students with concept mapping].

PubMed

Paucard-Dupont, Sylvie; Marchand, Claire

2014-06-01

The training reference leading to the state nursing diploma places the learning of clinical reasoning at the center of the training. We have been wondering about the possibilities of making visible the student nurse's mental processes when they provide nursing care in order to identify their strategies and reasoning difficulties. It turns out that concept mapping is a research tool capable of showing these two aspects. The aim of this study is to verify a concept mapping made during an interview and built from the speech of a nursing student when analyzing a simulated clinical situation, is able to make visible its strategies clinical reasoning and reasoning difficulties. In a second phase of it, is to explore how the concept map once elaborated allows students to identify their own intellectual reasoning. 12 nursing second year students have participated in the study. Concept maps were constructed by the trainer/researcher as the students analyzed aloud a simulated clinical situation written. Concept maps were analyzed from a reference grid. Interviews were conducted following the elaboration of concept maps and student's comments were analyzed. Students reasoning strategies were either mixed inductive dominant (5/12) or hypothetical-deductive dominant (5/12). Reasoning difficulties identified are related to the lack of identification of important information, the lack of analysis of data, lack of connection or the existence of faulty links. Analysis of the comments highlights that concept mapping contributed to the development of metacognitive skills. The concept mapping has shown benefits in contributing to a diagnostic assessment of clinical reasoning learning. It is an additional resource tool to facilitate the development of metacognitive skills for students. This tool can be useful to implement support learning strategies in clinical reasoning.

Clinical thinking in psychiatry.

PubMed

Wells, Lloyd A

2015-06-01

I discuss the lack of precision in the term 'clinical reasoning' and its relationship to evidence-based medicine and critical thinking. I examine critical thinking skills, their underemphasis in medical education and successful attempts to remediate them. Evidence-based medicine (and evidence-based psychiatry) offer much but are hampered by the ubiquity and flaws of meta-analysis. I explore views of evidence-based medicine among psychiatry residents, as well as capacity for critical thinking in residents before and after a course in philosophy. I discuss decision making by experienced doctors and suggest possible futures of this issue. © 2015 John Wiley & Sons, Ltd.

Learning to Reason: A Journey of Professional Socialisation

ERIC Educational Resources Information Center

Ajjawi, Rola; Higgs, Joy

2008-01-01

One of the key attributes that health professional students and new graduates develop during professional socialisation is clinical reasoning ability. Clinical reasoning is a complex skill that is essential for professional practice. There is limited research specifically addressing how physiotherapists learn to reason in the workplace. The…

Fuzzy logic and causal reasoning with an 'n' of 1 for diagnosis and treatment of the stroke patient.

PubMed

Helgason, Cathy M; Jobe, Thomas H

2004-03-01

The current scientific model for clinical decision-making is founded on binary or Aristotelian logic, classical set theory and probability-based statistics. Evidence-based medicine has been established as the basis for clinical recommendations. There is a problem with this scientific model when the physician must diagnose and treat the individual patient. The problem is a paradox, which is that the scientific model of evidence-based medicine is based upon a hypothesis aimed at the group and therefore, any conclusions cannot be extrapolated but to a degree to the individual patient. This extrapolation is dependent upon the expertise of the physician. A fuzzy logic multivalued-based scientific model allows this expertise to be numerically represented and solves the clinical paradox of evidence-based medicine.

Development and Validation of a Tool to Evaluate the Evolution of Clinical Reasoning in Trauma Using Virtual Patients.

PubMed

Fleiszer, David; Hoover, Michael L; Posel, Nancy; Razek, Tarek; Bergman, Simon

Undergraduate medical students at a large academic trauma center are required to manage a series of online virtual trauma patients as a mandatory exercise during their surgical rotation. Clinical reasoning during undergraduate medical education can be difficult to assess. The purpose of the study was to determine whether we could use components of the students' virtual patient management to measure changes in their clinical reasoning over the course of the clerkship year. In order to accomplish this, we decided to determine if the use of scoring rubrics could change the traditional subjective assessment to a more objective evaluation. Two groups of students, one at the beginning of clerkship (Juniors) and one at the end of clerkship (Seniors), were chosen. Each group was given the same virtual patient case, a clinical scenario based on the Advanced Trauma Life Support (ATLS) Primary Trauma Survey, which had to be completed during their trauma rotation. The learner was required to make several key patient management choices based on their clinical reasoning, which would take them along different routes through the case. At the end of the case they had to create a summary report akin to sign-off. These summaries were graded independently by two domain "Experts" using a traditional subjective surgical approach to assessment and by two "Non-Experts" using two internally validated scoring rubrics. One rubric assessed procedural or domain knowledge (Procedural Rubric), while the other rubric highlighted semantic qualifiers (Semantic Rubric). Each of the rubrics was designed to reflect established components of clinical reasoning. Student's t-tests were used to compare the rubric scores for the two groups and Cohen's d was used to determine effect size. Kendall's τ was used to compare the difference between the two groups based on the "Expert's" subjective assessment. Inter-rater reliability (IRR) was determined using Cronbach's alpha. The Seniors did better than the Juniors with respect to "Procedural" issues but not for "Semantic" issues using the rubrics as assessed by the "Non-Experts". The average Procedural rubric score for the Senior group was 59% ± 13% while for the junior group, it was 51% ± 12% (t (80) = 2.715; p = 0.008; Cohen's d = 1.53). The average Semantic rubric score for the Senior group was 31% ± 15% while for the Junior group, it was 28% ± 14% (t (80) = 1.010; p = .316, ns). There was no statistical difference in the marks given to the Senior versus Junior groups by the "Experts" (Kendall's τ = 0.182, p = 0.07). The IRR between the "Non-Experts" using the rubrics was higher than the IRR of the "Experts" using the traditional surgical approach to assessment. The Cronbach's alpha for the Procedural and Semantic rubrics was 0.94 and 0.97, respectively, indicating very high IRR. The correlation between the Procedural rubric scores and "Experts" assessment was approximately r = 0.78, and that between the Semantic rubric and the "Experts" assessment was roughly r = 0.66, indicating high concurrent validity for the Procedural rubric and moderately high validity for the Semantic rubric. Clinical reasoning, as measured by some of its "procedural" features, improves over the course of the clerkship year. Rubrics can be created to objectively assess the summary statement of an online interactive trauma VP for "procedural" issues but not for "semantic" issues. Using IRR as a measure, the quality of assessment is improved using the rubrics. The "Procedural" rubric appears to measure changes in clinical reasoning over the course of 3rd-year undergraduate clinical studies. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Reasons People Give for Using (or Not Using) Condoms.

PubMed

Farrington, Elizabeth M; Bell, David C; DiBacco, Aron E

2016-12-01

Study participants (N = 348) were asked about 46 reasons that have been suggested for why people use or do not use condoms. Participants were asked which of these reasons motivated them when they were deciding whether to use condoms in 503 sexual relationships. Participants were classified into one of three roles based on their HIV status and the status of each sexual partner: HIV+ people with HIV- partners; HIV- people with HIV+ partners; and HIV- people with HIV- partners. Motivations were looked at in the context of each of these roles. Of the 46 reasons, only 15 were selected by at least 1/3 of the participants, and only seven were selected by at least half. Frequently reported reasons primarily concern protecting self and partner from STDs including HIV. Less frequently reported reasons involved social norms, effects of condoms on sex, and concern for the relationship. These findings have implications for clinical interventions.

Consequences of Contextual Factors on Clinical Reasoning in Resident Physicians

ERIC Educational Resources Information Center

McBee, Elexis; Ratcliffe, Temple; Picho, Katherine; Artino, Anthony R., Jr.; Schuwirth, Lambert; Kelly, William; Masel, Jennifer; van der Vleuten, Cees; Durning, Steven J.

2015-01-01

Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have…

Evaluating Evidence-Informed Clinical Reasoning Proficiency in Oral Practical Examinations

ERIC Educational Resources Information Center

Geisler, Paul R.; Hummel, Chris; Piebes, Sarah

2014-01-01

Clinical reasoning is the specific cognitive process used by health care practitioners to formulate accurate diagnoses for complex patient problems and to set up and carry out effective care. Athletic training students and practitioners need to develop and display effective clinical reasoning skills in the assessment of injury and illness as a…

Clinical and Radiographic Assessment of Reasons for Replacement of Metal- Ceramic Fixed Dental Prostheses in Patients Referring to Dental School.

PubMed

Al Refai, Roa'a; Saker, Samah

2018-01-01

The expected length of service and reasons for fixed dental prostheses (FDPs) replacement are a frequent inquiry by patients while the answers were mainly based on studies reports that was conducted outside the middle east region. This clinical and radiographic survey was constructed to assess and survey clinically and radiographically the reasons of replacement of metal-ceramic fixed dental prostheses, amongst patients reporting at dental school in Taibah University. Between January and May 2016, 151 patients were recruited for this study. Interview (include questions pertained to the length of service of the prosthesis, the nature of complaint as told by patient in her own words), clinical examination, intra-oral photographs, and periapical radiographs, were done by the researchers. The parameters assessed were secondary caries, open margins, loss of retention, failure of endodontic treatment of the abutment and periodontal diseases. A total number of 249 failed fixed dental prostheses were evaluated. Of which 180 (39.7%) were single crowns, 159 (35.0%) were retainers and 117 (25.8%) were pontics in 69 fixed partial denture. The most common reason for replacement of fixed restorations was periodontal diseases affecting 92.8% of all types' restorations, followed by defective margin in 90.4% of examined restoration, poor aesthetic in 88% of restorations, while periapical involvement was found in 85.5% of fixed dental prosthesis. The survival rates of fixed prostheses were not predictable, and no association was found between number of years in service and the number of restorations. The most common reasons for replacing single unit fixed dental prostheses are periodontal diseases and periapical involvement, while defective margins and poor aesthetic mainly associated with multi-unit fixed dental prostheses. Key words: Failure, Fixed dental prosthesis, Survival, Replacement.

The psychological and social characteristics of patients referred for NHS cosmetic surgery: quantifying clinical need.

PubMed

Cook, Sharon A; Rosser, Robert; Toone, Helen; James, M Ian; Salmon, Peter

2006-01-01

Elective cosmetic surgery is expanding in the UK in both the public and private sectors. Because resources are constrained, many cosmetic procedures are being excluded within the National Health Service. If guidelines on who can receive such surgery are to be evidence-based, information is needed about the level of dysfunction in patients referred for elective surgery and whether this is related to their degree of physical abnormality. Consecutive patients referred to a regional plastic surgery and burns unit for assessment for elective cosmetic surgery completed standardised measures of physical and psychosocial dysfunction, and indicated their perception of the degree of their abnormality and their preoccupation with it. We distinguished between patients referred for physical reasons or appearance reasons only, and compared levels of physical and psychosocial dysfunction in each with published values for community and clinical samples. Surgeons indicated patients' degree of objective abnormality, and we identified the relationship of dysfunction with perceived and objective abnormality and preoccupation. Whether patients sought surgery for physical or appearance reasons, physical function was normal. Those seeking surgery for appearance reasons only had moderate psychosocial dysfunction, but were not as impaired as clinical groups with psychological problems. Patients seeking the correction of minor skin lesions for purely appearance reasons reported excellent physical and psychosocial function. Level of function was related (negatively) to patients' preoccupation with abnormality rather than to their perceived or objective abnormality. In general, patients referred for elective cosmetic surgery did not present with significant levels of dysfunction. Moreover, levels of functioning were related to preoccupation rather than to objective abnormality. Therefore, for most patients, whether surgical treatment is generally appropriate is questionable. Future guidelines must seek to identify the small minority who do have a clinical need for surgery.

Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm.

PubMed

Wang, Wendy T J; Olson, Sharon L; Campbell, Anne H; Hanten, William P; Gleeson, Peggy B

2003-03-01

The purpose of this study was to determine the effectiveness of an individualized physical therapy intervention in treating neck pain based on a clinical reasoning algorithm. Treatment effectiveness was examined by assessing changes in impairment, physical performance, and disability in response to intervention. One treatment group of 30 patients with neck pain completed physical therapy treatment. The control group of convenience was formed by a cohort group of 27 subjects who also had neck pain but did not receive treatment for various reasons. There were no significant differences between groups in demographic data and the initial test scores of the outcome measures. A quasi-experimental, nonequivalent, pretest-posttest control group design was used. A physical therapist rendered an eclectic intervention to the treatment group based on a clinical decision-making algorithm. Treatment outcome measures included the following five dependent variables: cervical range of motion, numeric pain rating, timed weighted overhead endurance, the supine capital flexion endurance test, and the Patient Specific Functional Scale. Both the treatment and control groups completed the initial and follow-up examinations, with an average duration of 4 wk between tests. Five mixed analyses of variance with follow-up tests showed a significant difference for all outcome measures in the treatment group compared with the control group. After an average 4 wk of physical therapy intervention, patients in the treatment group demonstrated statistically significant increases of cervical range of motion, decrease of pain, increases of physical performance measures, and decreases in the level of disability. The control group showed no differences in all five outcome variables between the initial and follow-up test scores. This study delineated algorithm-based clinical reasoning strategies for evaluating and treating patients with cervical pain. The algorithm can help clinicians classify patients with cervical pain into clinical patterns and provides pattern-specific guidelines for physical therapy interventions. An organized and specific physical therapy program was effective in improving the status of patients with neck pain.

Medication-related clinical decision support alert overrides in inpatients.

PubMed

Nanji, Karen C; Seger, Diane L; Slight, Sarah P; Amato, Mary G; Beeler, Patrick E; Her, Qoua L; Dalleur, Olivia; Eguale, Tewodros; Wong, Adrian; Silvers, Elizabeth R; Swerdloff, Michael; Hussain, Salman T; Maniam, Nivethietha; Fiskio, Julie M; Dykes, Patricia C; Bates, David W

2018-05-01

To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons. We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons. Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate. Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue. Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.

Data-Gathering, Belief Flexibility, and Reasoning Across the Psychosis Continuum

PubMed Central

Peters, Emmanuelle; Jackson, Mike; Day, Fern; Garety, Philippa A

2018-01-01

Abstract Background There is evidence for a group of nonclinical individuals with full-blown, persistent psychotic experiences (PEs) but no need-for-care: they are of particular importance in identifying risk and protective factors for clinical psychosis. The aim of this study was to investigate whether reasoning biases are related to PEs or need-for-care. Method Two groups with persistent PEs (clinical; n = 74; nonclinical; n = 92) and a control group without PEs (n = 83) were compared on jumping-to-conclusions (JTC) and belief flexibility. A randomly selected subset of interviews (n = 104) was analyzed to examine differences in experiential and rational reasoning. Results As predicted JTC was more common in the clinical than the other 2 groups. Unexpectedly no group differences were observed between clinical and nonclinical groups on measures of belief flexibility. However, the clinical group was less likely to employ rational reasoning, while the nonclinical group was more likely to use experiential reasoning plus a combination of both types of reasoning processes, compared to the other 2 groups. Conclusions Reasoning biases differ in groups with PEs with and without need-for-care. JTC is associated with need-for-care rather than with PEs. The ability to invoke rational reasoning processes, together with an absence of JTC, may protect against pathological outcomes of persistent PEs. However, marked use of experiential reasoning is associated with the occurrence of PEs in both clinical and nonclinical groups. Implications for theory development, intervention and further research are discussed. PMID:28338872

Upper extremity paraesthesia: clinical assessment and reasoning.

PubMed

Muscolino, Joseph E

2008-07-01

The art of clinical assessment involves an accurate determination of the cause(s) of a patient's symptoms. Given that a set of symptoms can be influenced by many contributing factors and features, assessment needs to differentially evaluate these. Accurate and appropriate treatment depends on differential assessment based on sound clinical reasoning. Many conditions derive from multiple causes demanding evaluation of as many etiological features as can be identified. The case review presented here involves a patient presenting with paraesthesia spreading into her right upper extremity. A complex history, involving her neck and contralateral upper extremity was assessed. The patient was found to have at least seven underlying, predisposing, and etiological, conditions capable of initiating, aggravating, or maintaining the presenting symptoms. Weighing the relative contributions of these often interacting features, and correlating this with the history, helped to identify a successful course of treatment.

Effectiveness of problem based learning as an instructional tool for acquisition of content knowledge and promotion of critical thinking among medical students.

PubMed

Tayyeb, Rakhshanda

2013-01-01

To assess effectiveness of PBL as an instructional tool in clinical years to improve learning of undergraduate students in terms of acquisition of content knowledge, critical thinking and problem solving skills through problem based learning and traditional way of teaching. Quasi-experimental study. Fatima Jinnah Medical College for Women, Lahore, from October 2009 to April 2010. Final year medical students attending Obstetrics and Gynaecology and Surgery rotations were inducted as participants in this study. Two batches of 50 students each attended Gynaecology rotation and two batches attended Surgery rotation, i.e. 100 students in each. Each batch was divided into two groups i.e. A and B of 25 students each. Group-A learnt through traditional teaching, involving bedside teaching and lectures in wards and Group-B learnt relevant clinical knowledge through a modified PBL process. Content knowledge was tested by MCQs testing recall while clinical reasoning and problem were assessed by MCQs testing analysis and critical thinking. Intra-group comparison of mean scores of pre and post-test scores was done using paired sample t-tests while for intergroup comparison of mean scores was done through independent sample t-test. Teaching through traditional method significantly improved content knowledge, (p = 0.001) but did not considerably improve clinical reasoning and problem solving skills (p = 0.093) whereas, content knowledge of students who studied through PBL remained the same (p = 0.202) but there was marked improvement in their clinical reasoning and problem solving skills (p = < 0.001). PBL is an effective instructional tool to foster critical thinking and problem solving skills among medical students.

Varieties of clinical reasoning.

PubMed

Bolton, Jonathan W

2015-06-01

Clinical reasoning comprises a variety of different modes of inference. The modes that are practiced will be influenced by the sociological characteristics of the clinical settings and the tasks to be performed by the clinician. This article presents C.S. Peirce's typology of modes of inference: deduction, induction and abduction. It describes their differences and their roles as stages in scientific argument. The article applies the typology to reasoning in clinical settings. The article describes their differences, and their roles as stages in scientific argument. It then applies the typology to reasoning in typical clinical settings. Abduction is less commonly taught or discussed than induction and deduction. However, it is a common mode of inference in clinical settings, especially when the clinician must try to make sense of a surprising phenomenon. Whether abduction is followed up with deductive and inductive verification is strongly influenced by situational constraints and the cognitive and psychological stamina of the clinician. Recognizing the inevitability of abduction in clinical practice and its value to discovery is important to an accurate understanding of clinical reasoning. © 2015 John Wiley & Sons, Ltd.

Recognition and privacy preservation of paper-based health records.

PubMed

Fenz, Stefan; Heurix, Johannes; Neubauer, Thomas

2012-01-01

While the digitization of medical data within electronic health records has been introduced in some areas, massive amounts of paper-based health records are still produced on a daily basis. This data has to be stored for decades due to legal reasons but is of no benefit for research organizations, as the unstructured medical data in paper-based health records cannot be efficiently used for clinical studies. This paper presents a system for the recognition and privacy preservation of personal data in paper-based health records with the aim to provide clinical studies with medical data gained from existing paper-based health records.

Diagnostic reasoning: where we've been, where we're going.

PubMed

Monteiro, Sandra M; Norman, Geoffrey

2013-01-01

Recently, clinical diagnostic reasoning has been characterized by "dual processing" models, which postulate a fast, unconscious (System 1) component and a slow, logical, analytical (System 2) component. However, there are a number of variants of this basic model, which may lead to conflicting claims. This paper critically reviews current theories and evidence about the nature of clinical diagnostic reasoning. We begin by briefly discussing the history of research in clinical reasoning. We then focus more specifically on the evidence to support dual-processing models. We conclude by identifying knowledge gaps about clinical reasoning and provide suggestions for future research. In contrast to work on analytical and nonanalytical knowledge as a basis for reasoning, these theories focus on the thinking process, not the nature of the knowledge retrieved. Ironically, this appears to be a revival of an outdated concept. Rather than defining diagnostic performance by problem-solving skills, it is now being defined by processing strategy. The version of dual processing that has received most attention in the literature in medical diagnosis might be labeled a "default/interventionist" model,(17) which suggests that a default system of cognitive processes (System 1) is responsible for cognitive biases that lead to diagnostic errors and that System 2 intervenes to correct these errors. Consequently, from this model, the best strategy for reducing errors is to make students aware of the biases and to encourage them to rely more on System 2. However, an accumulation of evidence suggests that (a) strategies directed at increasing analytical (System 2) processing, by slowing down, reducing distractions, paying conscious attention, and (b) strategies directed at making students aware of the effect of cognitive biases, have no impact on error rates. Conversely, strategies based on increasing application of relevant knowledge appear to have some success and are consistent with basic research on concept formation.

Context and clinical reasoning : Understanding the medical student perspective.

PubMed

McBee, Elexis; Ratcliffe, Temple; Schuwirth, Lambert; O'Neill, Daniel; Meyer, Holly; Madden, Shelby J; Durning, Steven J

2018-04-27

Studies have shown that a physician's clinical reasoning performance can be influenced by contextual factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of medical students in order to describe what impact the presence of contextual factors has on their reasoning performance. Seventeen medical student participants viewed three video recordings of clinical encounters portraying straightforward diagnostic cases in internal medicine with explicit contextual factors inserted. Participants completed a computerized post-encounter form as well as a think-aloud protocol. Three authors analyzed verbatim transcripts from the think-aloud protocols using a constant comparative approach. After iterative coding, utterances were analyzed and grouped into categories and themes. Six categories and ten associated themes emerged, which demonstrated overlap with findings from previous studies in resident and attending physicians. Four overlapping categories included emotional disturbances, behavioural inferences about the patient, doctor-patient relationship, and difficulty with closure. Two new categories emerged to include anchoring and misinterpretation of data. The presence of contextual factors appeared to impact clinical reasoning performance in medical students. The data suggest that a contextual factor can be innate to the clinical scenario, consistent with situated cognition theory. These findings build upon our understanding of clinical reasoning performance from both a theoretical and practical perspective.

Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education.

PubMed

Cooke, Suzette; Lemay, Jean-Francois

2017-06-01

In an age where practicing physicians have access to an overwhelming volume of clinical information and are faced with increasingly complex medical decisions, the ability to execute sound clinical reasoning is essential to optimal patient care. The authors propose two concepts that are philosophically paramount to the future assessment of clinical reasoning in medicine: assessment in the context of "uncertainty" (when, despite all of the information that is available, there is still significant doubt as to the best diagnosis, investigation, or treatment), and acknowledging that it is entirely possible (and reasonable) to have more than "one correct answer." The purpose of this article is to highlight key elements related to these two core concepts and discuss genuine barriers that currently exist on the pathway to creating such assessments. These include acknowledging situations of uncertainty, creating clear frameworks that define progressive levels of clinical reasoning skills, providing validity evidence to increase the defensibility of such assessments, considering the comparative feasibility with other forms of assessment, and developing strategies to evaluate the impact of these assessment methods on future learning and practice. The authors recommend that concerted efforts be directed toward these key areas to help advance the field of clinical reasoning assessment, improve the clinical care decisions made by current and future physicians, and have positive outcomes for patients. It is anticipated that these and subsequent efforts will aid in reaching the goal of making future assessment in medical education more representative of current-day clinical reasoning and decision making.

Designing Trials for Testing the Efficacy of Pre- Pro- and Synbiotics

NASA Astrophysics Data System (ADS)

Lewis, Stephen; Atkinson, Charlotte

Providing an evidence base for the rational delivery of medicines and treatments is the cornerstone of modern health care delivery. Much of this evidence base is gained through conducting clinical trials. Superficially, designing a clinical trial seems straightforward. However, in practice many unforeseen difficulties arise with long setting up times, poor recruitment rates and patients or interventions not behaving in the way expected. Unfortunately, clinical trials examining the efficacy of pre-, pro- and synbiotics have developed a reputation for being published in low impact journals and reaching unconvincing conclusions. As a generalization, the reason for this poor reputation is that the trials have tended to be too small and have not used meaningful clinical endpoints.

21 CFR 601.91 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2013 CFR

2013-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible § 601.91 Approval based on evidence of effectiveness from... reasonably likely to produce clinical benefit in humans. In assessing the sufficiency of animal data, the...

21 CFR 601.91 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2014 CFR

2014-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible § 601.91 Approval based on evidence of effectiveness from... reasonably likely to produce clinical benefit in humans. In assessing the sufficiency of animal data, the...

21 CFR 601.91 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2012 CFR

2012-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS LICENSING Approval of Biological Products When Human Efficacy Studies Are Not Ethical or Feasible § 601.91 Approval based on evidence of effectiveness from... reasonably likely to produce clinical benefit in humans. In assessing the sufficiency of animal data, the...

Nursing Faculty Experiences of Virtual Learning Environments for Teaching Clinical Reasoning

ERIC Educational Resources Information Center

Zacharzuk-Marciano, Tara

2017-01-01

Nurses need sharp, clinical reasoning skills to respond to critical situations and to be successful at work in a complex and challenging healthcare system. While past research has focused on using virtual learning environments to teach clinical reasoning, there has been limited research on the experiences of nursing faculty and there is a need for…

The Lived-Experience of Novice Nurse's Actualizing Clinical Reasoning in Academic Simulation

ERIC Educational Resources Information Center

Brinker, Mary Catherine

2016-01-01

The purpose of this existential-phenomenological study was to address the first-person perspective of what it is like to experience clinical reasoning during a simulation. It was not known how a novice nurse would describe the experience of actualizing clinical reasoning during the academic simulation experience. In order to maintain the…

Interpreting clinical trial results by deductive reasoning: In search of improved trial design.

PubMed

Kurbel, Sven; Mihaljević, Slobodan

2017-10-01

Clinical trial results are often interpreted by inductive reasoning, in a trial design-limited manner, directed toward modifications of the current clinical practice. Deductive reasoning is an alternative in which results of relevant trials are combined in indisputable premises that lead to a conclusion easily testable in future trials. © 2017 WILEY Periodicals, Inc.

iSMART: Ontology-based Semantic Query of CDA Documents

PubMed Central

Liu, Shengping; Ni, Yuan; Mei, Jing; Li, Hanyu; Xie, Guotong; Hu, Gang; Liu, Haifeng; Hou, Xueqiao; Pan, Yue

2009-01-01

The Health Level 7 Clinical Document Architecture (CDA) is widely accepted as the format for electronic clinical document. With the rich ontological references in CDA documents, the ontology-based semantic query could be performed to retrieve CDA documents. In this paper, we present iSMART (interactive Semantic MedicAl Record reTrieval), a prototype system designed for ontology-based semantic query of CDA documents. The clinical information in CDA documents will be extracted into RDF triples by a declarative XML to RDF transformer. An ontology reasoner is developed to infer additional information by combining the background knowledge from SNOMED CT ontology. Then an RDF query engine is leveraged to enable the semantic queries. This system has been evaluated using the real clinical documents collected from a large hospital in southern China. PMID:20351883

Advantages of video trigger in problem-based learning.

PubMed

Chan, Lap Ki; Patil, Nivritti G; Chen, Julie Y; Lam, Jamie C M; Lau, Chak S; Ip, Mary S M

2010-01-01

Traditionally, paper cases are used as 'triggers' to stimulate learning in problem-based learning (PBL). However, video may be a better medium because it preserves the original language, encourages the active extraction of information, avoids depersonalization of patients and allows direct observation of clinical consultations. In short, it exposes the students to the complexity of actual clinical problems. The study aims to find out whether students and facilitators who are accustomed to paper cases would prefer video triggers or paper cases and the reasons for their preference. After students and facilitators had completed a video PBL tutorial, their responses were measured by a structured questionnaire using a modified Likert scale. A total of 257 students (92%) and 26 facilitators (100%) responded. The majority of students and facilitators considered that using video triggers could enhance the students' observational powers and clinical reasoning, help them to integrate different information and better understand the cases and motivate them to learn. They found PBL using video triggers more interesting and preferred it to PBL using paper cases. Video triggers are preferred by both students and facilitators over paper cases in PBL.

A unified framework for the evaluation of surrogate endpoints in mental-health clinical trials.

PubMed

Molenberghs, Geert; Burzykowski, Tomasz; Alonso, Ariel; Assam, Pryseley; Tilahun, Abel; Buyse, Marc

2010-06-01

For a number of reasons, surrogate endpoints are considered instead of the so-called true endpoint in clinical studies, especially when such endpoints can be measured earlier, and/or with less burden for patient and experimenter. Surrogate endpoints may occur more frequently than their standard counterparts. For these reasons, it is not surprising that the use of surrogate endpoints in clinical practice is increasing. Building on the seminal work of Prentice(1) and Freedman et al.,(2) Buyse et al. (3) framed the evaluation exercise within a meta-analytic setting, in an effort to overcome difficulties that necessarily surround evaluation efforts based on a single trial. In this article, we review the meta-analytic approach for continuous outcomes, discuss extensions to non-normal and longitudinal settings, as well as proposals to unify the somewhat disparate collection of validation measures currently on the market. Implications for design and for predicting the effect of treatment in a new trial, based on the surrogate, are discussed. A case study in schizophrenia is analysed.

Neonatal physical therapy. Part I: clinical competencies and neonatal intensive care unit clinical training models.

PubMed

Sweeney, Jane K; Heriza, Carolyn B; Blanchard, Yvette

2009-01-01

To describe clinical training models, delineate clinical competencies, and outline a clinical decision-making algorithm for neonatal physical therapy. In these updated practice guidelines, advanced clinical training models, including precepted practicum and residency or fellowship training, are presented to guide practitioners in organizing mentored, competency-based preparation for neonatal care. Clinical competencies in neonatal physical therapy are outlined with advanced clinical proficiencies and knowledge areas specific to each role. An algorithm for decision making on examination, evaluation, intervention, and re-examination processes provides a framework for clinical reasoning. Because of advanced-level competency requirements and the continuous examination, evaluation, and modification of procedures during each patient contact, the intensive care unit is a restricted practice area for physical therapist assistants, physical therapist generalists, and physical therapy students. Accountable, ethical physical therapy for neonates requires advanced, competency-based training with a preceptor in the pediatric subspecialty of neonatology.

Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians.

PubMed

McBee, Elexis; Ratcliffe, Temple; Picho, Katherine; Schuwirth, Lambert; Artino, Anthony R; Yepes-Rios, Ana Monica; Masel, Jennifer; van der Vleuten, Cees; Durning, Steven J

2017-11-15

The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual "stimulus" to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in board certified internists versus resident physicians. Each participant viewed three videotaped clinical encounters portraying common diagnoses in internal medicine. We explicitly modified the context to assess its impact on performance (patient and physician contextual factors). Patient contextual factors, including English as a second language and emotional volatility, were portrayed in the videos. Physician participant contextual factors were self-rated sleepiness and burnout.. The accuracy of diagnostic and therapeutic reasoning was compared with covariates using Fisher Exact, Mann-Whitney U tests and Spearman Rho's correlations as appropriate. Fifteen board certified internists and 10 resident physicians participated from 2013 to 2014. Accuracy of diagnostic and therapeutic reasoning did not differ between groups despite residents reporting significantly higher rates of sleepiness (mean rank 20.45 vs 8.03, U = 0.5, p < .001) and burnout (mean rank 20.50 vs 8.00, U = 0.0, p < .001). Accuracy of diagnosis and treatment were uncorrelated (r = 0.17, p = .65). In both groups, the proportion scoring correct responses for treatment was higher than the proportion scoring correct responses for diagnosis. This study underscores that specific contextual factors appear to impact clinical reasoning performance. Further, the processes of diagnostic and therapeutic reasoning, although related, may not be interchangeable. This raises important questions about the impact that contextual factors have on clinical reasoning and provides insight into how clinical reasoning processes in more authentic settings may be explained by situated cognition theory.

A Preschool Obesity Treatment Clinical Trial: Reasons Primary Care Providers Declined Referrals.

PubMed

Robson, Shannon M; Bolling, Christopher; McCullough, Mary Beth; Stough, Cathleen Odar; Stark, Lori J

2016-10-01

To examine referral by primary care providers (PCPs) of preschool children with obesity (≥95th percentile for body mass index [BMI]) to a weight management intervention when offered through a randomized clinical trial (RCT), and identify reasons for not referring children. In phase I, 3 experts in obesity, psychology, and nutrition completed an open card sort and classified PCPs' reasons for declining referral into groups based on similarity of reasons. Categories were then defined and labeled. In phase II, 2 independent sorters placed each decline into 1 of the categories defined in phase I. PCPs referred 78% of eligible children to the RCT. Compared with children declined for referral, referred children had a significantly higher weight (48.4 lb vs 46.1 lb; P < .001) and BMI percentile (97.6 vs 97.0; P < .001). Eleven categories for decline were identified in phase I. In phase II, excellent reliability was obtained between each independent sorter and the phase I categories, and also between the 2 independent sorters (κ values, 0.72-1.0). The most common reason for declining was "family not a good fit" (23.6%), followed by "doesn't believe weight is a problem" (13.9%), "family would not be interested" (12%), and "doesn't believe measurement is accurate" (11.5%). Appropriately, exclusionary criteria of the RCT was a reason as well (11.8%). The availability of weight management for preschoolers through RCTs appeared to overcome barriers of resources, time, and credible treatment cited in previous studies. However, concerns about the family's response or interest in a weight management program remained barriers, as did PCPs' perceptions about obesity in young children. ClinicalTrials.gov:NCT01546727. Copyright © 2016 Elsevier Inc. All rights reserved.

Women's reasons for choosing abortion method: A systematic literature review.

PubMed

Kanstrup, Charlotte; Mäkelä, Marjukka; Hauskov Graungaard, Anette

2017-07-01

We aim to describe and classify reasons behind women's choice between medical and surgical abortion. A systematic literature review was conducted in PubMed and PsycINFO in October 2015. The subjects were women in early pregnancy opting for abortion at clinics or hospitals in high-income countries. We extracted women's reasons for choice of abortion method and analysed these qualitatively, looking at main reasons for choosing either medical or surgical abortion. Reasons for choice of method were classified to five main groups: technical nature of the intervention, fear of complications, fear of surgery or anaesthesia, timing and sedation. Reasons for selecting medical abortion were often based on the perception of the method being 'more natural' and the wish to have abortion in one's home in addition to fear of complications. Women who opted for surgical abortion appreciated the quicker process, viewed it as the safer option, and wished to avoid pain and excess bleeding. Reasons were often based on emotional reactions, previous experiences and a lack of knowledge about the procedures. Some topics such as pain or excess bleeding received little attention. Overall the quality of the studies was low, most studies were published more than 10 years ago, and the generalisability of the findings was poor. Women did not base their choice of abortion method only on rational information from professionals but also on emotions and especially fears. Support techniques for a more informed choice are needed. Recent high-quality studies in this area are lacking.

Wisdom in clinical reasoning and medical practice.

PubMed

Edmondson, Ricca; Pearce, Jane; Woerner, Markus H

2009-01-01

Exploring informal components of clinical reasoning, we argue that they need to be understood via the analysis of professional wisdom. Wise decisions are needed where action or insight is vital, but neither everyday nor expert knowledge provides solutions. Wisdom combines experiential, intellectual, ethical, emotional and practical capacities; we contend that it is also more strongly social than is usually appreciated. But many accounts of reasoning specifically rule out such features as irrational. Seeking to illuminate how wisdom operates, we therefore build on Aristotle's work on informal reasoning. His account of rhetorical communication shows how non-formal components can play active parts in reasoning, retaining, or even enhancing its reasonableness. We extend this account, applying it to forms of healthcare-related reasoning which are characterised by the need for wise decision-making. We then go on to explore some of what clinical wise reasoning may mean, concluding with a case taken from psychotherapeutic practice.

Reasoning process characteristics in the diagnostic skills of beginner, competent, and expert dentists.

PubMed

Crespo, Kathleen E; Torres, José E; Recio, María E

2004-12-01

The purpose of this study was to evaluate qualitative differences in the diagnostic reasoning process at different developmental stages of expertise. A qualitative design was used to study cognitive processes that characterize the diagnosis of oral disease at the stages of beginner (five junior students who had passed the NBDE I), competent (five GPR first-year residents), and expert dentists (five general dentists with ten or more years of experience). Individually, each participant was asked to determine the diagnosis of an oral condition based on a written clinical case, using the think aloud technique and retrospective reports. A subsequent interview was conducted to obtain the participants' diagnostic process model and pathophysiology of the case. The analysis of the verbal protocols indicated that experts referred to the patient's sociomedical context more frequently, demonstrated better organization of ideas, could determine key clinical findings, and had an ability to plan for the search of pertinent information. Fewer diagnostic hypotheses were formulated by participants who used forward reasoning, independent of the stage of development. Beginners requested additional diagnostic aids (radiographs, laboratory tests) more frequently than the competent/expert dentists. Experts recalled typical experiences with patients, while competent/beginner dentists recalled information from didactic courses. Experts evidenced cognitive diagnostic schemas that integrate pathophysiology of disease, while competent and beginner participants had not achieved this integration. We conclude that expert performance is a combination of a knowledge base, reasoning skills, and an accumulation of experiences with patients that is qualitatively different from that of competent and beginner dentists. It is important for dental education to emphasize the teaching of cognitive processes and to incorporate a wide variety of clinical experiences in addition to the teaching of disciplinary content.

Data-Gathering, Belief Flexibility, and Reasoning Across the Psychosis Continuum.

PubMed

Ward, Thomas; Peters, Emmanuelle; Jackson, Mike; Day, Fern; Garety, Philippa A

2018-01-13

There is evidence for a group of nonclinical individuals with full-blown, persistent psychotic experiences (PEs) but no need-for-care: they are of particular importance in identifying risk and protective factors for clinical psychosis. The aim of this study was to investigate whether reasoning biases are related to PEs or need-for-care. Two groups with persistent PEs (clinical; n = 74; nonclinical; n = 92) and a control group without PEs (n = 83) were compared on jumping-to-conclusions (JTC) and belief flexibility. A randomly selected subset of interviews (n = 104) was analyzed to examine differences in experiential and rational reasoning. As predicted JTC was more common in the clinical than the other 2 groups. Unexpectedly no group differences were observed between clinical and nonclinical groups on measures of belief flexibility. However, the clinical group was less likely to employ rational reasoning, while the nonclinical group was more likely to use experiential reasoning plus a combination of both types of reasoning processes, compared to the other 2 groups. Reasoning biases differ in groups with PEs with and without need-for-care. JTC is associated with need-for-care rather than with PEs. The ability to invoke rational reasoning processes, together with an absence of JTC, may protect against pathological outcomes of persistent PEs. However, marked use of experiential reasoning is associated with the occurrence of PEs in both clinical and nonclinical groups. Implications for theory development, intervention and further research are discussed. © The Author 2017. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.

Reasons for Ineligibility in Phase 1 and 2A HIV Vaccine Clinical Trials at Kenya Aids Vaccine Initiative (KAVI), Kenya

PubMed Central

Omosa-Manyonyi, Gloria S.; Jaoko, Walter; Anzala, Omu; Ogutu, Hilda; Wakasiaka, Sabina; Malogo, Roselyn; Nyange, Jacqueline; Njuguna, Pamela; Ndinya-Achola, Jeckoniah; Bhatt, Kirana; Farah, Bashir; Oyaro, Micah; Schmidt, Claudia; Priddy, Frances; Fast, Patricia

2011-01-01

Background With the persistent challenges towards controlling the HIV epidemic, there is an ongoing need for research into HIV vaccines and drugs. Sub-Saharan African countries - worst affected by the HIV pandemic - have participated in the conduct of clinical trials for HIV vaccines. In Kenya, the Kenya AIDS Vaccine Initiative (KAVI) at the University of Nairobi has conducted HIV vaccine clinical trials since 2001. Methodology Participants were recruited after an extensive informed consent process followed by screening to determine eligibility. Screening included an assessment of risk behavior, medical history and physical examination, and if clinically healthy, laboratory testing. In the absence of locally derived laboratory reference ranges, the ranges used in these trials were derived from populations in the West. Principal findings Two hundred eighty-one participants were screened between 2003 and 2006 for two clinical trials. Of these, 167 (59.4%) met the inclusion/exclusion criteria. Overall, laboratory abnormalities based on the non-indigenous laboratory references used were the most frequent reasons (61.4%) for ineligibility. Medical abnormalities contributed 30.7% of the total reasons for ineligibility. Based on the laboratory reference intervals now developed from East and Southern Africa, those ineligible due to laboratory abnormalities would have been 46.3%. Of the eligible participants, 18.6% declined enrolment. Conclusions Participant recruitment for HIV vaccine clinical trials is a rigorous and time-consuming exercise. Over 61% of the screening exclusions in clinically healthy people were due to laboratory abnormalities. It is essential that laboratory reference ranges generated from local populations for laboratory values be used in the conduct of clinical trials to avoid unnecessary exclusion of willing participants and to avoid over-reporting of adverse events for enrolled participants. Trial registration Protocol IAVI VRC V001 [1]. ClinicalTrials.gov NCT00124007 Protocol IAVI 010 [2] (registration with ClincalTrials.gov is in progress) Protocols IAVI 002 and IAVI 004 are Phase 1 trials only mentioned in introductory paragraphs; details will not be reported. Registration was not required when they were conducted. PMID:21283743

How Exemplary Inpatient Teaching Physicians Foster Clinical Reasoning.

PubMed

Houchens, Nathan; Harrod, Molly; Fowler, Karen E; Moody, Stephanie; Saint, Sanjay

2017-09-01

Clinical reasoning is a crucial component of training in health professions. These cognitive skills are necessary to provide quality care and avoid diagnostic error. Much previous literature has focused on teaching clinical reasoning in nonclinical environments and does not include learner reflections. The authors sought to explore, through multiple perspectives including learners, techniques used by exemplary inpatient clinician-educators for explicitly cultivating clinical reasoning. The authors conducted (2014-2015) a multisite, exploratory qualitative study examining how excellent clinician-educators foster clinical reasoning during general medicine rounds. This was accomplished through interviews of educators, focus group discussions with learners, and direct observations of clinical teaching. The authors reviewed field notes and transcripts using techniques of thematic analysis. Twelve clinician-educators, 57 current learners, and 26 former learners participated in observations and interviews. The techniques and behaviors of educators were categorized into 4 themes, including 1) emphasizing organization and prioritization, 2) accessing prior knowledge, 3) thinking aloud, and 4) analyzing the literature. The findings of this comprehensive study both confirm strategies found in previous literature and provide novel approaches. This is the first study to incorporate the perspectives of learners. Educators' techniques and behaviors, identified through direct observation and supported by reflections from the entire team, can inform best practices for the teaching of clinical reasoning. Copyright © 2017 Elsevier Inc. All rights reserved.

Working Memory, Reasoning, and Expertise in Medicine--Insights into Their Relationship Using Functional Neuroimaging

ERIC Educational Resources Information Center

Hruska, Pam; Krigolson, Olav; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Hecker, Kent G.

2016-01-01

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical…

An Investigation into the Clinical Reasoning Development of Veterinary Students.

PubMed

Vinten, Claire E K; Cobb, Kate A; Freeman, Sarah L; Mossop, Liz H

Clinical reasoning is a fundamental skill for veterinary clinicians and a competency required of graduates by the Royal College of Veterinary Surgeons. However, it is unknown how veterinary students develop reasoning skills and where strengths and shortcomings of curricula lie. This research aimed to use the University of Nottingham School of Veterinary Medicine and Science (SVMS) as a case study to investigate the development of clinical reasoning among veterinary students. The analysis was framed in consideration of the taught, learned, and declared curricula. Sixteen staff and sixteen students from the SVMS participated separately in a total of four focus groups. In addition, five interviews were conducted with recent SVMS graduates. Audio transcriptions were used to conduct a thematic analysis. A content analysis was performed on all curriculum documentation. It was found that SVMS graduates feel they have a good level of reasoning ability, but they still experience a deficit in their reasoning capabilities when starting their first job. Overarching themes arising from the data suggest that a lack of responsibility for clinical decisions during the program and the embedded nature of the clinical reasoning skill within the curriculum could be restricting development. In addition, SVMS students would benefit from clinical reasoning training where factors influencing "real life" decisions (e.g., finances) are explored in more depth. Integrating these factors into the curriculum could lead to improved decision-making ability among SVMS graduates and better prepare students for the stressful transition to practice. These findings are likely to have implications for other veterinary curricula.

The use of emotional intelligence capabilities in clinical reasoning and decision-making: A qualitative, exploratory study.

PubMed

Hutchinson, Marie; Hurley, John; Kozlowski, Desirée; Whitehair, Leeann

2018-02-01

To explore clinical nurses' experiences of using emotional intelligence capabilities during clinical reasoning and decision-making. There has been little research exploring whether, or how, nurses employ emotional intelligence (EI) in clinical reasoning and decision-making. Qualitative phase of a larger mixed-methods study. Semistructured qualitative interviews with a purposive sample of registered nurses (n = 12) following EI training and coaching. Constructivist thematic analysis was employed to analyse the narrative transcripts. Three themes emerged: the sensibility to engage EI capabilities in clinical contexts, motivation to actively engage with emotions in clinical decision-making and incorporating emotional and technical perspectives in decision-making. Continuing to separate cognition and emotion in research, theorising and scholarship on clinical reasoning is counterproductive. Understanding more about nurses' use of EI has the potential to improve the calibre of decisions, and the safety and quality of care delivered. © 2017 John Wiley & Sons Ltd.

Ethics and eplerenone.

PubMed

Gupta, Shruti; Fugh-Berman, Adriane J; Scialli, Anthony

2013-02-01

The use of a placebo arm in clinical trials is unethical if there is an active comparator that is acceptably safe and effective. We argue that reasonable evidence of effectiveness and safety of an inexpensive alternative to an expensive therapy is sufficient to require that the inexpensive therapy be included as a comparator when the expensive therapy is tested, and that use of an inactive placebo comparator only is not ethical. For example, studies of the expensive drug eplerenone for congestive heart failure have not included a spironolactone arm, although there is reasonable evidence that spironolactone would be safe and effective, and spironolactone is inexpensive. The requirement to study inexpensive therapies is based on avoidance of unnecessary cost in medical care as an example of non-maleficence. Several ethical actors in the design, conduct, and publication of clinical trials and their results bear responsibility for the appropriate conduct of clinical trials. That responsibility includes protecting study subjects from being asked to participate in clinical trials that serve primarily to promote the use of new and expensive therapies.

Framework for a clinical information system.

PubMed

Van De Velde, R; Lansiers, R; Antonissen, G

2002-01-01

The design and implementation of Clinical Information System architecture is presented. This architecture has been developed and implemented based on components following a strong underlying conceptual and technological model. Common Object Request Broker and n-tier technology featuring centralised and departmental clinical information systems as the back-end store for all clinical data are used. Servers located in the "middle" tier apply the clinical (business) model and application rules. The main characteristics are the focus on modelling and reuse of both data and business logic. Scalability as well as adaptability to constantly changing requirements via component driven computing are the main reasons for that approach.

The Computer-based Lecture

PubMed Central

Wofford, Marcia M; Spickard, Anderson W; Wofford, James L

2001-01-01

Advancing computer technology, cost-containment pressures, and desire to make innovative improvements in medical education argue for moving learning resources to the computer. A reasonable target for such a strategy is the traditional clinical lecture. The purpose of the lecture, the advantages and disadvantages of “live” versus computer-based lectures, and the technical options in computerizing the lecture deserve attention in developing a cost-effective, complementary learning strategy that preserves the teacher-learner relationship. Based on a literature review of the traditional clinical lecture, we build on the strengths of the lecture format and discuss strategies for converting the lecture to a computer-based learning presentation. PMID:11520384

The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic.

PubMed

Seif, Gretchen; Coker-Bolt, Patty; Kraft, Sara; Gonsalves, Wanda; Simpson, Kit; Johnson, Emily

2014-11-01

This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p = 0.03) and perceptions of clinical reasoning skills when compared to the control group (p = 0.002). This study is novel as it examined students' perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.

Defining Staged Procedures for Percutaneous Coronary Intervention Trials: A Guidance Document.

PubMed

Spitzer, Ernest; McFadden, Eugène; Vranckx, Pascal; de Vries, Ton; Ren, Ben; Collet, Carlos; Onuma, Yoshinobu; Garcia-Garcia, Hector M; Lopes, Renato D; Stone, Gregg W; Cutlip, Donald E; Serruys, Patrick W

2018-05-14

Patients in coronary intervention trials may require more than 1 procedure to complete the intended revascularization strategy. However, these staged interventions are not consistently defined. Standardized definitions are needed to allow meaningful comparisons of this outcome among trials. This document provides guidance on relevant parameters involving staged procedures, including minimum data collection and consistent classification of coronary procedures initially identified as staged; the aim is to achieve consistency among clinical trialists, sponsors, health authorities, and regulators. Definitions were developed jointly among representatives of academic institutions and clinical research organizations based on clinical trial experience and published literature. Reasons for staged procedures were identified and include baseline kidney function, contrast load and radiation exposure, lesion complexity, and patient or operator fatigue. Moreover, nonclinical reasons include procedure scheduling and reimbursement. Management of staged procedures should be a standalone section in clinical trial protocols and clinical events committee charters. These documents should clearly define a time window for staged procedures that allows latitude for local policies, while respecting accepted clinical guidelines, and consistency with study objectives. Investigators should document in the case report form the intent to stage a procedure, the lesions to be treated, and the reasons for staging, preferably before randomization. Ideally, all reinterventions, or at least all procedures performed after the recommended time window, those in which data suggest an anticipated procedure due to a worsening condition and those where a revascularization is attempted in the target vessel, should be reviewed by an independent clinical events committee. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Consequences of contextual factors on clinical reasoning in resident physicians.

PubMed

McBee, Elexis; Ratcliffe, Temple; Picho, Katherine; Artino, Anthony R; Schuwirth, Lambert; Kelly, William; Masel, Jennifer; van der Vleuten, Cees; Durning, Steven J

2015-12-01

Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think-aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. This finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.

21 CFR 314.510 - Approval based on a surrogate endpoint or on an effect on a clinical endpoint other than survival...

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 5 2011-04-01 2011-04-01 false Approval based on a surrogate endpoint or on an... Serious or Life-Threatening Illnesses § 314.510 Approval based on a surrogate endpoint or on an effect on... the drug product has an effect on a surrogate endpoint that is reasonably likely, based on...

21 CFR 314.510 - Approval based on a surrogate endpoint or on an effect on a clinical endpoint other than survival...

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 5 2014-04-01 2014-04-01 false Approval based on a surrogate endpoint or on an... Serious or Life-Threatening Illnesses § 314.510 Approval based on a surrogate endpoint or on an effect on... the drug product has an effect on a surrogate endpoint that is reasonably likely, based on...

21 CFR 314.510 - Approval based on a surrogate endpoint or on an effect on a clinical endpoint other than survival...

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 5 2013-04-01 2013-04-01 false Approval based on a surrogate endpoint or on an... Serious or Life-Threatening Illnesses § 314.510 Approval based on a surrogate endpoint or on an effect on... the drug product has an effect on a surrogate endpoint that is reasonably likely, based on...

21 CFR 314.510 - Approval based on a surrogate endpoint or on an effect on a clinical endpoint other than survival...

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 5 2012-04-01 2012-04-01 false Approval based on a surrogate endpoint or on an... Serious or Life-Threatening Illnesses § 314.510 Approval based on a surrogate endpoint or on an effect on... the drug product has an effect on a surrogate endpoint that is reasonably likely, based on...

Reasoning, evidence, and clinical decision-making: The great debate moves forward.

PubMed

Loughlin, Michael; Bluhm, Robyn; Buetow, Stephen; Borgerson, Kirstin; Fuller, Jonathan

2017-10-01

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. © 2017 John Wiley & Sons, Ltd.

Optimizing participation of children with autism spectrum disorder experiencing sensory challenges: a clinical reasoning framework.

PubMed

Ashburner, Jill K; Rodger, Sylvia A; Ziviani, Jenny M; Hinder, Elizabeth A

2014-02-01

Remedial sensory interventions currently lack supportive evidence and can be challenging to implement for families and clinicians. It may be timely to shift the focus to optimizing participation of children with autism spectrum disorders (ASD) through accommodation and self-regulation of their sensory differences. A framework to guide practitioners in selecting strategies is proposed based on clinical reasoning considerations, including (a) research evidence, (b) client- and family-centredness, (c) practice contexts, (d) occupation-centredness, and (e) risks. Information-sharing with families and coaching constitute the basis for intervention. Specific strategies are identified where sensory aversions or seeking behaviours, challenges with modulation of arousal, or sensory-related behaviours interfere with participation. Self-regulatory strategies are advocated. The application of universal design principles to shared environments is also recommended. The implications of this framework for future research, education, and practice are discussed. The clinical utility of the framework now needs to be tested.

Integrating research into clinical internship training bridging the science/practice gap in pediatric psychology.

PubMed

McQuaid, Elizabeth L; Spirito, Anthony

2012-03-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a "capstone experience"; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the "business of science." Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.

Technical Note: FreeCT_ICD: An Open Source Implementation of a Model-Based Iterative Reconstruction Method using Coordinate Descent Optimization for CT Imaging Investigations.

PubMed

Hoffman, John M; Noo, Frédéric; Young, Stefano; Hsieh, Scott S; McNitt-Gray, Michael

2018-06-01

To facilitate investigations into the impacts of acquisition and reconstruction parameters on quantitative imaging, radiomics and CAD using CT imaging, we previously released an open source implementation of a conventional weighted filtered backprojection reconstruction called FreeCT_wFBP. Our purpose was to extend that work by providing an open-source implementation of a model-based iterative reconstruction method using coordinate descent optimization, called FreeCT_ICD. Model-based iterative reconstruction offers the potential for substantial radiation dose reduction, but can impose substantial computational processing and storage requirements. FreeCT_ICD is an open source implementation of a model-based iterative reconstruction method that provides a reasonable tradeoff between these requirements. This was accomplished by adapting a previously proposed method that allows the system matrix to be stored with a reasonable memory requirement. The method amounts to describing the attenuation coefficient using rotating slices that follow the helical geometry. In the initially-proposed version, the rotating slices are themselves described using blobs. We have replaced this description by a unique model that relies on tri-linear interpolation together with the principles of Joseph's method. This model offers an improvement in memory requirement while still allowing highly accurate reconstruction for conventional CT geometries. The system matrix is stored column-wise and combined with an iterative coordinate descent (ICD) optimization. The result is FreeCT_ICD, which is a reconstruction program developed on the Linux platform using C++ libraries and the open source GNU GPL v2.0 license. The software is capable of reconstructing raw projection data of helical CT scans. In this work, the software has been described and evaluated by reconstructing datasets exported from a clinical scanner which consisted of an ACR accreditation phantom dataset and a clinical pediatric thoracic scan. For the ACR phantom, image quality was comparable to clinical reconstructions as well as reconstructions using open-source FreeCT_wFBP software. The pediatric thoracic scan also yielded acceptable results. In addition, we did not observe any deleterious impact in image quality associated with the utilization of rotating slices. These evaluations also demonstrated reasonable tradeoffs in storage requirements and computational demands. FreeCT_ICD is an open-source implementation of a model-based iterative reconstruction method that extends the capabilities of previously released open source reconstruction software and provides the ability to perform vendor-independent reconstructions of clinically acquired raw projection data. This implementation represents a reasonable tradeoff between storage and computational requirements and has demonstrated acceptable image quality in both simulated and clinical image datasets. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Evaluation of a clinical needs assessment and exploration of the associated supports for students with a disability in clinical practice: part 2.

PubMed

Howlin, Frances; Halligan, Phil; O'Toole, Sinead

2014-09-01

Engagement and successful completion of nursing and midwifery programmes may be predicated on the identification and implementation of reasonable accommodations to facilitate clinical learning for students with a disability. This qualitative study aims to evaluate a clinical needs assessment for students with a disability and explore their experiences of support in clinical practice. A purposive sample of year one undergraduate students was used. Four students consented to participate and undertook an individual interview. Their disabilities were categorised as specific learning disability (dyslexia) (n = 3) and mental health (n = 1). Data analysis revealed two main themes 'students' experiences of disclosure' and 'receiving support'. Findings revealed that all students disclosed on placement, however, the extent of disclosure was influenced by personal and environmental factors. Students used the clinical needs assessment to highlight accommodations to clinical staff on placement. Issues of concern that arose, included communication between all key stakeholders, negative staff attitudes and the need to improve the provision of accommodations. This preliminary evaluation indicates that the Clinical Needs Assessment bridges the gap in provision of student support between higher education and healthcare institutions. Findings suggest that competence based needs assessments can identify individualised reasonable accommodations for students undertaking clinical placements. Copyright © 2014 Elsevier Ltd. All rights reserved.

Major Anthropogenic Causes for and Outcomes of Wild Animal Presentation to a Wildlife Clinic in East Tennessee, USA, 2000–2011

PubMed Central

Schenk, Ashley N.; Souza, Marcy J.

2014-01-01

To determine the reasons for presentation and outcome of wildlife cases in East Tennessee, a retrospective analysis was performed using 14,303 records from cases presented to the wildlife clinic of the University of Tennessee Veterinary Teaching Hospital between 2000 and 2011. The cases were first categorized into amphibian/non-avian reptile, mammal, or avian and then classified into groups based on the primary admitting/presenting sign. There are a variety of reasons animals were presented to the clinic, and some were directly or indirectly anthropogenic in origin, including cat related, dog related, hit by automobile, and other human encounters leading to trauma; of the cases reviewed, 4,443 (31.1%) presented for one of these 4 reasons. Overall case fatality risk in regard to these 4 admitting/presenting signs was 0.519 for the amphibian/non-avian reptile cases, 0.675 for mammal cases, and 0.687 for avian cases. This study confirms the importance of monitoring wildlife morbidity and mortality and of focusing efforts to reduce the anthropogenic threat on native habitats and resident wildlife populations. PMID:24686490

Yield of Echocardiogram and Predictors of Positive Yield in Pediatric Patients: A Study in an Urban, Community-Based Outpatient Pediatric Cardiology Clinic.

PubMed

Billa, Ramya Deepthi; Szpunar, Susan; Zeinali, Lida; Anne, Premchand

2018-01-01

The yield of outpatient echocardiograms varies based on the indication for the echocardiogram and the age of the patient. The purpose of this study was to determine the cumulative yield of outpatient echocardiograms by age group and reason for the test. A secondary aim was to determine the predictors of a positive echocardiogram in an outpatient cardiology clinic at a large community teaching hospital. We retrospectively reviewed the charts of 891 patients who had a first-time echocardiogram between 2011 and 2015. Positive yield was defined as echocardiographic findings that explained the reason for the echocardiogram. The overall positive yield was 8.2%. Children between birth and 3 months of age had the highest yield (34.2%), and children between 12 and 18 years of age had the lowest yield (1%). Patients with murmurs (18.1%) had the highest yield compared with patients with other signs or symptoms. By age group and reason, the highest yields were as follows: 0 to 3 months of age, murmur (39.2%); 4 to 11 months of age, >1 symptom (50%); and 1 to 5 years of age, shortness of breath (66.7%). Based on our study, the overall yield of echocardiograms in the outpatient pediatric setting is low. Age and symptoms should be considered before ordering an echocardiogram.

Application of a temporal reasoning framework tool in analysis of medical device adverse events.

PubMed

Clark, Kimberly K; Sharma, Deepak K; Chute, Christopher G; Tao, Cui

2011-01-01

The Clinical Narrative Temporal Relation Ontology (CNTRO)1 project offers a semantic-web based reasoning framework, which represents temporal events and relationships within clinical narrative texts, and infer new knowledge over them. In this paper, the CNTRO reasoning framework is applied to temporal analysis of medical device adverse event files. One specific adverse event was used as a test case: late stent thrombosis. Adverse event narratives were obtained from the Food and Drug Administration's (FDA) Manufacturing and User Facility Device Experience (MAUDE) database2. 15 adverse event files in which late stent thrombosis was confirmed were randomly selected across multiple drug eluting stent devices. From these files, 81 events and 72 temporal relations were annotated. 73 temporal questions were generated, of which 65 were correctly answered by the CNTRO system. This results in an overall accuracy of 89%. This system should be pursued further to continue assessing its potential benefits in temporal analysis of medical device adverse events.

Reasons for quitting among emerging adults and adolescents in substance-use-disorder treatment.

PubMed

Smith, Douglas C; Cleeland, Leah; Dennis, Michael L

2010-05-01

Understanding developmental differences in reasons for quitting substance use may assist clinicians in tailoring treatments to different clinical populations. This study investigates whether alcohol-disordered and problem-drinking emerging adults (i.e., ages 18-25 years) have different reasons for quitting than younger adolescents (i.e., ages 13-17 years). Using a large clinical sample of emerging adults and adolescents, we compared endorsement rates for 26 separate reasons for quitting between emerging adults and adolescents who were matched on clinical severity. Then age group was regressed on total, interpersonal, and personal reasons for quitting, and mediation tests were conducted with variables proposed to be developmentally salient to emerging adults. Among both age groups, self-control reasons were the most highly endorsed. Emerging adults had significantly fewer interpersonal reasons for quitting (Cohen's d = 0.20), and this association was partially mediated by days of being in trouble with one's family. There were no differences in personal reasons or total number of reasons for quitting. Our findings are consistent with developmental theory suggesting that emerging adults experience less social control, which here leads to less interpersonal motivation to refrain from alcohol and drug use. As emerging adults in clinical samples may indicate few interpersonal reasons for quitting, one challenge to tailoring treatments for them will be identifying innovative ways of leveraging social supports and altering existing social networks.

[Paradigmatic shifts in clinical practice in the the last generation].

PubMed

Benbassat, J

1996-05-01

Physicians have always used theoretical models (paradigms) to interpret clinical reality, and have changed the prevailing model only when it could no longer satisfy clinical needs. The purpose of this essay is to review some of the paradigmatic changes in clinical reasoning that have occurred since my undergraduate medial education. My training in the 50's was along the bio-medical model that reduced all diseases to structural or biochemical dysfunctions. Within this framework, causes were perceived as leading inevitably rather than probabilistically to their consequences, and chance and ambiguity had a very small role in explication of pathophysiologic mechanisms and in diagnostic reasoning. The doctor-patient relationship was paternalistic and the orientation to extending survival rejected notions of quality of life and involved parsimonious utilization of health care resources. Today however, clinical reasoning has shifted from deductive and deterministic to inductive (evidence-based) and probabilistic. Disease is believed to result from multiple factors rather than from single causes, and there is increasing acceptance of psycho-social factors of disease. Awareness of the confounding effects of false-positive and false-negative tests has changed the attitude to diagnostic evaluation. Terms, such as risk indicators of disease, predictive value of tests and risk-benefit ratio are increasingly used in discussing clinical decisions. We respect the patient's autonomy more than we did in the past, and consider his/her preferences and quality of life in clinical decision-making. Fair distribution of medical resources is considered as an ethical principle. Finally, clinical guidelines are no longer viewed as counter-intuitive, but rather as effective means to reduce the disturbingly high rates of medical error.

EVIDENCE – BASED MEDICINE/PRACTICE IN SPORTS PHYSICAL THERAPY

PubMed Central

Lehecka, B.J.

2012-01-01

A push for the use of evidence‐based medicine and evidence‐based practice patterns has permeated most health care disciplines. The use of evidence‐based practice in sports physical therapy may improve health care quality, reduce medical errors, help balance known benefits and risks, challenge views based on beliefs rather than evidence, and help to integrate patient preferences into decision‐making. In this era of health care utilization sports physical therapists are expected to integrate clinical experience with conscientious, explicit, and judicious use of research evidence in order to make clearly informed decisions in order to help maximize and optimize patient well‐being. One of the more common reasons for not using evidence in clinical practice is the perceived lack of skills and knowledge when searching for or appraising research. This clinical commentary was developed to educate the readership on what constitutes evidence‐based practice, and strategies used to seek evidence in the daily clinical practice of sports physical therapy. PMID:23091778

Evidence - based medicine/practice in sports physical therapy.

PubMed

Manske, Robert C; Lehecka, B J

2012-10-01

A push for the use of evidence-based medicine and evidence-based practice patterns has permeated most health care disciplines. The use of evidence-based practice in sports physical therapy may improve health care quality, reduce medical errors, help balance known benefits and risks, challenge views based on beliefs rather than evidence, and help to integrate patient preferences into decision-making. In this era of health care utilization sports physical therapists are expected to integrate clinical experience with conscientious, explicit, and judicious use of research evidence in order to make clearly informed decisions in order to help maximize and optimize patient well-being. One of the more common reasons for not using evidence in clinical practice is the perceived lack of skills and knowledge when searching for or appraising research. This clinical commentary was developed to educate the readership on what constitutes evidence-based practice, and strategies used to seek evidence in the daily clinical practice of sports physical therapy.

Neural basis of nonanalytical reasoning expertise during clinical evaluation.

PubMed

Durning, Steven J; Costanzo, Michelle E; Artino, Anthony R; Graner, John; van der Vleuten, Cees; Beckman, Thomas J; Wittich, Christopher M; Roy, Michael J; Holmboe, Eric S; Schuwirth, Lambert

2015-03-01

Understanding clinical reasoning is essential for patient care and medical education. Dual-processing theory suggests that nonanalytic reasoning is an essential aspect of expertise; however, assessing nonanalytic reasoning is challenging because it is believed to occur on the subconscious level. This assumption makes concurrent verbal protocols less reliable assessment tools. Functional magnetic resonance imaging was used to explore the neural basis of nonanalytic reasoning in internal medicine interns (novices) and board-certified staff internists (experts) while completing United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. The results demonstrated that novices and experts share a common neural network in addition to nonoverlapping neural resources. However, experts manifested greater neural processing efficiency in regions such as the prefrontal cortex during nonanalytical reasoning. These findings reveal a multinetwork system that supports the dual-process mode of expert clinical reasoning during medical evaluation.

Neighborhood graph and learning discriminative distance functions for clinical decision support.

PubMed

Tsymbal, Alexey; Zhou, Shaohua Kevin; Huber, Martin

2009-01-01

There are two essential reasons for the slow progress in the acceptance of clinical case retrieval and similarity search-based decision support systems; the especial complexity of clinical data making it difficult to define a meaningful and effective distance function on them and the lack of transparency and explanation ability in many existing clinical case retrieval decision support systems. In this paper, we try to address these two problems by introducing a novel technique for visualizing inter-patient similarity based on a node-link representation with neighborhood graphs and by considering two techniques for learning discriminative distance function that help to combine the power of strong "black box" learners with the transparency of case retrieval and nearest neighbor classification.

[Development and clinical evaluation of an anesthesia information management system].

PubMed

Feng, Jing-yi; Chen, Hua; Zhu, Sheng-mei

2010-09-21

To study the design, implementation and clinical evaluation of an anesthesia information management system. To record, process and store peri-operative patient data automatically, all kinds of bedside monitoring equipments are connected into the system based on information integrating technology; after a statistical analysis of those patient data by data mining technology, patient status can be evaluated automatically based on risk prediction standard and decision support system, and then anesthetist could perform reasonable and safe clinical processes; with clinical processes electronically recorded, standard record tables could be generated, and clinical workflow is optimized, as well. With the system, kinds of patient data could be collected, stored, analyzed and archived, kinds of anesthesia documents could be generated, and patient status could be evaluated to support clinic decision. The anesthesia information management system is useful for improving anesthesia quality, decreasing risk of patient and clinician, and aiding to provide clinical proof.

Application of 4G wireless network-based system for remote diagnosis and nursing of stomal complications

PubMed Central

Xu, Xiulian; Cao, Yingjuan; Luan, Xiaorong

2014-01-01

Background: This study aims to apply 4G wireless network in the remote diagnosis of stoma complications for the first time. Background: Remote diagnosis and nursing care for a variety of illnesses are urgently needed in clinical settings. Objectives: Combining with relevant clinical manifestations, an Android phone-based intelligent diagnosis system was designed to construct a universe, easy access to exploitation and human-computer interaction database and exploitation environment for applications and programs. Methods: “Production rule” and forward reasoning method were utilized to design arborescence structures and logic reasoner associated with stoma complications. Stoma physicians were responsible for delivering evaluation scores on patients’ health status using analytic hierarchy process. The emphasis of this study is to exploit an “Android phone-based system for remote diagnosis of stoma”, which is of certain universe usage. Results: Such system was tested in the Medicine Information Center of Qilu Hospital of Shandong University and initially applied in the city of De Zhou, Shandong province, China. Conclusions: These results collectively demonstrated that the system is easy to carry, of high utility and free from the limitations of wire network environment, etc. It provides clinical evidence for establishing a novel type model for the exchange between patients and physicians. PMID:25550986

A competency-based approach to nurses' continuing education for clinical reasoning and leadership through reflective practice in a care situation.

PubMed

Goudreau, Johanne; Pepin, Jacinthe; Larue, Caroline; Dubois, Sylvie; Descôteaux, Renée; Lavoie, Patrick; Dumont, Katia

2015-11-01

Newly graduated nurses need to demonstrate high levels of competencies when they enter the workplace. A competency-based approach to their education is recommended to ensure patients' needs are met. A continuing education intervention consistent with the competency-based approach to education was designed and implemented in eight care units in two teaching hospitals. It consists of a series of 30-min reflective practice groups on clinical events that newly graduated nurses encountered in their practice. It was evaluated using a descriptive longitudinal evaluative research design, combining individual and group interviews with stakeholders, the analysis of facilitators' journal entries, and a research assistant's field notes. The results suggest that issues associated with the implementation of the continuing education intervention revolved around leadership for managers, flexibility for nursing staff, and role shifting for the facilitators. Newly graduated nurses who participated in the study noted that the reflective practice sessions contributed to the development of both clinical reasoning and leadership. Nursing managers stated the advantages of the intervention on nurses' professional development and for the quality and safety of care. Following the end of the study, participants from two units managed to pursue the activity during their work time. Copyright © 2015 Elsevier Ltd. All rights reserved.

Toward translational incremental similarity-based reasoning in breast cancer grading

NASA Astrophysics Data System (ADS)

Tutac, Adina E.; Racoceanu, Daniel; Leow, Wee-Keng; Müller, Henning; Putti, Thomas; Cretu, Vladimir

2009-02-01

One of the fundamental issues in bridging the gap between the proliferation of Content-Based Image Retrieval (CBIR) systems in the scientific literature and the deficiency of their usage in medical community is based on the characteristic of CBIR to access information by images or/and text only. Yet, the way physicians are reasoning about patients leads intuitively to a case representation. Hence, a proper solution to overcome this gap is to consider a CBIR approach inspired by Case-Based Reasoning (CBR), which naturally introduces medical knowledge structured by cases. Moreover, in a CBR system, the knowledge is incrementally added and learned. The purpose of this study is to initiate a translational solution from CBIR algorithms to clinical practice, using a CBIR/CBR hybrid approach. Therefore, we advance the idea of a translational incremental similarity-based reasoning (TISBR), using combined CBIR and CBR characteristics: incremental learning of medical knowledge, medical case-based structure of the knowledge (CBR), image usage to retrieve similar cases (CBIR), similarity concept (central for both paradigms). For this purpose, three major axes are explored: the indexing, the cases retrieval and the search refinement, applied to Breast Cancer Grading (BCG), a powerful breast cancer prognosis exam. The effectiveness of this strategy is currently evaluated over cases provided by the Pathology Department of Singapore National University Hospital, for the indexing. With its current accuracy, TISBR launches interesting perspectives for complex reasoning in future medical research, opening the way to a better knowledge traceability and a better acceptance rate of computer-aided diagnosis assistance among practitioners.

Integrating home-based medication therapy management (MTM) services in a health system.

PubMed

Reidt, Shannon; Holtan, Haley; Stender, Jennifer; Salvatore, Toni; Thompson, Bruce

2016-01-01

To describe the integration of home-based Medication Therapy Management (MTM) into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Minnesota from September 2012 to December 2013. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Home-based MTM was promoted throughout the clinics within the health system. Physicians, advanced practice providers, nurses, and pharmacists could refer patients to receive MTM in their homes. A home visit had the components of a clinic-based visit and was documented in the electronic health record (EHR); however, providing the service in the home allowed for a more direct assessment of environmental factors affecting medication use. Number of home MTM referrals, reason for referral and type of referring provider, number and type of medication-related problems (MRPs). In the first 15 months, 74 home visits were provided to 53 patients. Sixty-six percent of the patients were referred from the Internal Medicine Clinic. Referrals were also received from the senior care, coordinated care, and psychiatry clinics. Approximately 50% of referrals were made by physicians. More referrals (23%) were made by pharmacists compared with advanced practice providers, who made 21% of referrals. The top 3 reasons for referral were: nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse. Patients had a median of 3 MRPs with the most common (40%) MRP related to compliance. Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service. Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Relating the Components of the Clinical Reasoning Process to the Construction of Patient Management Problems

PubMed Central

Skakun, Ernest N.

1982-01-01

Patient Management Problems (PMPs) are frequently used to test a physician's ability in conducting a medical work-up. The construction of PMPs has been inhibited because the clinical reasoning process with which these simulations deal has not been described until recently. The clinical reasoning process is reviewed and broad guidelines for constructing PMPs to reflect the components of the process are presented.

Effects of an experiential learning program on the clinical reasoning and critical thinking skills of occupational therapy students.

PubMed

Coker, Patty

2010-01-01

This study examined the effects of participation in a 1-week, experiential, hands-on learning program on the critical thinking and clinical reasoning skills of occupational therapy students. A quasi-experimental, nonrandomized pre- and post-test design was used with a sample of 25 students. The students had completed three semesters of didactic lecture coursework in a master's level OT educational program prior to participation in a hands-on therapy program for children with hemiplegic cerebral palsy. Changes in critical thinking and clinical reasoning skills were evaluated using the following dependent measures: Self-Assessment of Clinical Reflection and Reasoning (SACRR) and the California Critical Thinking Skills Test (CCTST). Changes in pretest and posttest scores on the SACRR and the CCTST were statistically significant (p>0.05) following completion of the experiential learning program. This study supports the use of hands-on learning to develop clinical reasoning and critical thinking skills in healthcare students, who face ever more diverse patient populations upon entry-level practice. Further qualitative and quantitative investigations are needed to support the results of this study and determine which components of experiential learning programs are essential for developing clinical reasoning and critical thinking skills in future allied health professionals.

Script-theory virtual case: A novel tool for education and research.

PubMed

Hayward, Jake; Cheung, Amandy; Velji, Alkarim; Altarejos, Jenny; Gill, Peter; Scarfe, Andrew; Lewis, Melanie

2016-11-01

Context/Setting: The script theory of diagnostic reasoning proposes that clinicians evaluate cases in the context of an "illness script," iteratively testing internal hypotheses against new information eventually reaching a diagnosis. We present a novel tool for teaching diagnostic reasoning to undergraduate medical students based on an adaptation of script theory. We developed a virtual patient case that used clinically authentic audio and video, interactive three-dimensional (3D) body images, and a simulated electronic medical record. Next, we used interactive slide bars to record respondents' likelihood estimates of diagnostic possibilities at various stages of the case. Responses were dynamically compared to data from expert clinicians and peers. Comparative frequency distributions were presented to the learner and final diagnostic likelihood estimates were analyzed. Detailed student feedback was collected. Over two academic years, 322 students participated. Student diagnostic likelihood estimates were similar year to year, but were consistently different from expert clinician estimates. Student feedback was overwhelmingly positive: students found the case was novel, innovative, clinically authentic, and a valuable learning experience. We demonstrate the successful implementation of a novel approach to teaching diagnostic reasoning. Future study may delineate reasoning processes associated with differences between novice and expert responses.

Factors associated with clinical inertia: an integrative review

PubMed Central

Aujoulat, Isabelle; Jacquemin, Patricia; Rietzschel, Ernst; Scheen, André; Tréfois, Patrick; Wens, Johan; Darras, Elisabeth; Hermans, Michel P

2014-01-01

Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia. PMID:24868181

The Group Objective Structured Clinical Experience: building communication skills in the clinical reasoning context.

PubMed

Konopasek, Lyuba; Kelly, Kevin V; Bylund, Carma L; Wenderoth, Suzanne; Storey-Johnson, Carol

2014-07-01

Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners' self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback. GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback. Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE. The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting. The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

A tool to enhance occupational therapy reasoning from ICF perspective: The Hasselt Occupational Performance Profile (H-OPP).

PubMed

Ghysels, R; Vanroye, E; Westhovens, M; Spooren, A

2017-03-01

In order to enhance occupational therapy reasoning in clinical practice, different elements such as client-centred approach, evidence-based care and interdisciplinary work should be taken into account, but is a challenge. To describe the development of the digital Hasselt Occupational Performance Profile (H-OPP © ) that enhances occupational therapy reasoning from ICF perspective. A participative qualitative design was used to create the H-OPP © in an iterative way in which occupational therapy lectures, ICF experts, students and occupational therapists in the field were involved. After linking occupational therapy terminology to the ICF, different stages of the H-OPP were identified and elaborated with main features: generating an occupational performance profile based on inventarization of problems and possibilities, formulating an occupational performance diagnosis and enabling to create an intervention plan. In all stages, both the perspectives of the client and the occupational therapist were taken into account. To increase practical use, the tool was further elaborated and digitalized. The H-OPP © is a digital coach that guides and facilitates professional reasoning in (novice) occupational therapists. It augments involvement of the client system. Furthermore, it enhances interdisciplinary communication and evidence-based care.

Theory-Based Analysis of Interest in an HIV Vaccine for Reasons Indicative of Risk Compensation Among African American Women.

PubMed

Painter, Julia E; Temple, Brandie S; Woods, Laura A; Cwiak, Carrie; Haddad, Lisa B; Mulligan, Mark J; DiClemente, Ralph J

2018-06-01

Licensure of an HIV vaccine could reduce or eliminate HIV among vulnerable populations. However, vaccine effectiveness could be undermined by risk compensation (RC), defined by an increase in risky behavior due to a belief that the vaccine will confer protection. Interest in an HIV vaccine for reasons indicative of RC may serve as an indicator of actual RC in a postlicensure era. This study assessed factors associated with interest in an HIV vaccine for reasons indicative of RC among African American women aged 18 to 55 years, recruited from a hospital-based family planning clinic in Atlanta, Georgia ( N = 321). Data were collected using audio-computer-assisted surveys. Survey items were guided by risk homeostasis theory and social cognitive theory. Multivariable logistic regression was used to assess determinants of interest in an HIV vaccine for reasons indicative of RC. Thirty-eight percent of the sample expressed interest in an HIV vaccine for at least one reason indicative of RC. In the final model, interest in an HIV vaccine for reasons indicative of RC was positively associated with higher impulsivity, perceived benefits of sexual risk behaviors, and perceived benefits of HIV vaccination; it was negatively associated with having at least some college education, positive future orientation, and self-efficacy for sex refusal. Results suggest that demographic, personality, and theory-based psychosocial factors are salient to wanting an HIV vaccine for reasons indicative of RC, and underscore the need for risk-reduction counseling alongside vaccination during the eventual rollout of an HIV vaccine.

ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association.

PubMed

Brindis, Ralph G; Douglas, Pamela S; Hendel, Robert C; Peterson, Eric D; Wolk, Michael J; Allen, Joseph M; Patel, Manesh R; Raskin, Ira E; Hendel, Robert C; Bateman, Timothy M; Cerqueira, Manuel D; Gibbons, Raymond J; Gillam, Linda D; Gillespie, John A; Hendel, Robert C; Iskandrian, Ami E; Jerome, Scott D; Krumholz, Harlan M; Messer, Joseph V; Spertus, John A; Stowers, Stephen A

2005-10-18

Under the auspices of the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC), an appropriateness review was conducted for radionuclide cardiovascular imaging (RNI), specifically gated single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). The review assessed the risks and benefits of the imaging test for several indications or clinical scenarios and scored them based on a scale of 1 to 9, where the upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The mid range (4 to 6) implies that the test may be generally acceptable and may be a reasonable approach for the indication. The indications for this review were primarily drawn from existing clinical practice guidelines and modified based on discussion by the ACCF Appropriateness Criteria Working Group and the Technical Panel members who rated the indications. The method for this review was based on the RAND/UCLA approach for evaluating appropriateness, which blends scientific evidence and practice experience. A modified Delphi technique was used to obtain first- and second-round ratings of 52 clinical indications. The ratings were done by a Technical Panel with diverse membership, including nuclear cardiologists, referring physicians (including an echocardiographer), health services researchers, and a payer (chief medical officer). These results are expected to have a significant impact on physician decision making and performance, reimbursement policy, and future research directions. Periodic assessment and updating of criteria will be undertaken as needed.

Apps in therapy: occupational therapists' use and opinions.

PubMed

Seifert, Anna M; Stotz, Nicole; Metz, Alexia E

2017-11-01

To gather information on occupational therapy practitioners' use and opinions of apps, an online survey was distributed to occupational therapy practitioners licensed in the state of Ohio. The survey sought information regarding clinical populations and skill areas for which apps are used, potential barriers to use of apps and preferred apps/app features. OTs working in medical and education-based settings and with clients of all ages responded to the survey. Over half (53%) reported not using apps in therapy, with "not having access to the technology at work" being the leading reason endorsed. Of practitioners who did report using apps, the majority used them with ≤25% of their case load and primarily used tablets to do so. Clinicians indicated that they use apps for a wide variety of reasons, including to promote skill building and to support the therapeutic process. Preferred features included the ability to grade difficulty up/down, multiple uses and accurate feedback. Recommendations from peers were the most commonly reported way respondents found new apps. The results suggest that occupational therapy practitioners employ clinical reasoning when implementing apps in therapy. Possible ways to improve access to apps for therapists who would like to implement them are discussed. Implications for Rehabilitation Many occupational therapy practitioners are using apps with at least a portion of their caseloads. Therapists select apps based on peer recommendations, most commonly selecting those which promote skill building and support the therapeutic process. More therapists might make use of apps if potential barriers were reduced or eliminated, including availability of technology in the clinical practice setting, therapist training and education, therapist input into app development and an enhanced evidence base.

Sponsor-Imposed Publication Restrictions Disclosed on ClinicalTrials.gov.

PubMed

Stretton, Serina; Lew, Rebecca A; Ely, Julie A; Snape, Mark J; Carey, Luke C; Haley, Cassandra; Woolley, Mark J; Woolley, Karen L

2016-01-01

We investigated whether sponsor-imposed publication restrictions for ClinicalTrials.gov trials were reasonable, based on consistency with Good Publication Practice 2 (GPP2). ClinicalTrials.gov trial record data were electronically imported (October 7, 2012) and screened for eligibility (phase 2-4, interventional, recruitment closed, results available, first received for registration after November 10, 2009, any sponsor type, investigators not sponsor employees). Two authors categorized restrictions information as consistent or not consistent with GPP2, resolving discrepancies by consensus. Of the eligible trials (388/484, n = 81,768 participants), 80.7% (313/388) had restrictions disclosed, and 92.5% (311/388) were industry-sponsored. Significantly more trials had restrictions that were consistent with GPP2 than not (74.1% [232/313], n = 55,280 participants vs. 25.9% [81/313], n = 19,677 participants; P < .001). Reasons for inconsistency were insufficient, unclear, or ambiguous information (48.1%, 39/81), sponsor-required approval for publication (35.8%, 29/81), sponsor-required text changes (8.6%, 7/81), and outright bans (7.4%, 6/81). Follow-up of trials with insufficient information and a contact email (response rate, 46.9% [15/32]) revealed 2 additional bans. A total of 776 participants had consented to trials that had publication bans. Many, but not all, sponsor-imposed publication restrictions disclosed on ClinicalTrials.gov may be considered reasonable. Sponsors should ensure restrictions are appropriately disclosed. Volunteers should be alerted to any restrictions before consenting to participate in a clinical trial.

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory.

PubMed

Pelaccia, Thierry; Tardif, Jacques; Triby, Emmanuel; Charlin, Bernard

2011-03-14

Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward. This paper aims at exploring a comprehensive approach: the "dual-process theory", a model developed by cognitive psychologists over the last few years. After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians' intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

The role of clinician emotion in clinical reasoning: Balancing the analytical process.

PubMed

Langridge, Neil; Roberts, Lisa; Pope, Catherine

2016-02-01

This review paper identifies and describes the role of clinicians' memory, emotions and physical responses in clinical reasoning processes. Clinical reasoning is complex and multi-factorial and key models of clinical reasoning within musculoskeletal physiotherapy are discussed, highlighting the omission of emotion and subsequent physical responses and how these can impact upon a clinician when making a decision. It is proposed that clinicians should consider the emotions associated with decision-making, especially when there is concern surrounding a presentation. Reflecting on practice in the clinical environment and subsequently applying this to a patient presentation should involve some acknowledgement of clinicians' physical responses, emotions and how they may play a part in any decision made. Presenting intuition and gut-feeling as separate reasoning methods and how these processes co-exist with other more accepted reasoning such as hypothetico-deductive is also discussed. Musculoskeletal physiotherapy should consider the elements of feelings, emotions and physical responses when applying reflective practice principles. Furthermore, clinicians dealing with difficult and challenging presentations should look at the emotional as well as the analytical experience when justifying decisions and learning from practice. Copyright © 2015 Elsevier Ltd. All rights reserved.

A Learner-Centered Technique and Clinical Reasoning, Reflection, and Case Presentation Attributes in Athletic Training Students

PubMed Central

Heinerichs, Scott; Vela, Luzita I.; Drouin, Joshua M.

2013-01-01

Context: Providing opportunities to develop clinical decision-making skills, including clinical reasoning, is an important aspect of clinical education. The learner-centered technique of summarizing the history and findings, narrowing the differential, analyzing the differential, probing the instructor about uncertainties, plan management, and selecting an issue for self-directed study (SNAPPS) is used in medicine to express clinical reasoning. Objective: To investigate the effects of SNAPPS on the clinical reasoning, reflection, and 4 case presentation attributes (length, conciseness, case summary, and expression of clinical reasoning) in athletic training students. Design: Randomized controlled clinical trial. Setting: Three undergraduate programs accredited by the Commission on Accreditation of Athletic Training Education. Patients or Other Participants: We randomly assigned 38 athletic training students (17 men, 21 women; age = 21.53 ± 1.18 years, grade point average = 3.25 ± 0.31) who had completed at least 1 year of clinical education and all orthopaedic evaluation coursework to the SNAPPS group or the usual and customary group using a stratification scheme. Intervention(s): The SNAPPS group completed four 45-minute clinical reasoning and case presentation learning modules led by an investigator to learn the SNAPPS technique, whereas the usual and customary group received no formal instruction. Both groups audio recorded all injury evaluations performed over a 2-week period. Main Outcome Measures: Participants completed the Diagnostic Thinking Inventory and Reflection in Learning Scale twice. Case presentations were analyzed for 4 attributes: length, conciseness, case summary, and expression of clinical reasoning. Results: Case presentations were longer (t18.806 = −5.862, P < .001) but were more concise (t32 = 11.297, P < .001) for the SNAPPS group than for the usual and customary group. The SNAPPS group performed better on both the case summary subscale (t32 = 2.857, P = .007) and the clinical reasoning subscale (t25.773 = −14.162, P < .001) than the other group. We found a time effect for Diagnostic Thinking Inventory scores (F1,34 = 6.230, P = .02) but observed no group effects (F1,34 = 0.698, P = .41) or time-by-group interaction (F1,34 = 1.050, P = .31). The Reflection in Learning Scale scores analysis revealed no group-by-time interaction (F1,34 = 1.470, P = .23) and no group (F1,34 = 3.751, P = .06) or time (F1,34 = 0.835, P = .37) effects. Conclusions: The SNAPPS is an effective and feasible clinical education technique for case presentations. This learner-centered technique provides the opportunity for the expression of clinical reasoning skills. PMID:23675796

Relationship of reasons and fears of treatment with outcome in substance using population attending a de-addiction centre.

PubMed

Sarkar, Siddharth; Nebhinani, Naresh; Kaur, Jasveen; Kaur, Kamalpreet; Ghai, Sandhya; Basu, Debasish

2013-07-01

Substance users approach a treatment facility for a variety of reasons as well as avoid or delay in help seeking due to perceived fears with treatment facilities. Sometimes these factors might be associated with treatment outcomes. We studied the relationship of reasons and fears of treatment seeking with treatment outcome in substance users. One hundred subjects, attending the Drug Deaddiction and Treatment Centre, PGIMER, were prospectively recruited by purposive sampling. A semistructured proforma was used to gather sociodemographic and clinical data. Reasons of help-seeking and fear questionnaire, social support scale, and PGI locus of control scale were then applied. Followup data were available for 69 patients, which were classified into good or poor outcome based on relapse status. At 6 months followup, 22 patients had relapsed, while 47 patients did not relapse. A higher degree of dysfunction due to substance at baseline was associated with relapsed status at followup. Parents or guardians coming to know about resuming substance and being unemployed for a long time were the reasons associated with relapsed status, while needing to consult a doctor immediately was significantly related to abstinent status at followup. Fear of not being able to meet substance using friends was associated with a poorer outcome in the form of relapse. Reasons for treatment seeking as well as fears related to treatment have significant implications on the clinical outcome of substance abusing patients. Addressing these could help in better patient outcomes.

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory.

PubMed

Kuiper, Ruth Anne; Pesut, Daniel J

2004-02-01

Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills. While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development. Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts. This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills. Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases. The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking. Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition. This skill acquisition is best accomplished through teaching-learning attention to self-regulation learning theory. A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory. It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development. Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development. While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts. Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies. The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts.

Residents' views of the role of classroom-based learning in graduate medical education through the lens of academic half days.

PubMed

Chen, Luke Y C; McDonald, Julie A; Pratt, Daniel D; Wisener, Katherine M; Jarvis-Selinger, Sandra

2015-04-01

To examine the role of classroom-based learning in graduate medical education through the lens of academic half days (AHDs) by exploring residents' perceptions of AHDs' purpose and relevance and the effectiveness of teaching and learning in AHDs. The authors invited a total of 186 residents in three programs (internal medicine, orthopedic surgery, and hematology) at the University of British Columbia Faculty of Medicine to participate in semistructured focus groups from October 2010 to February 2011. Verbatim transcripts of the interviews underwent inductive analysis. Twenty-seven residents across the three programs volunteered to participate. Two major findings emerged. Purpose and relevance of AHDs: Residents believed that AHDs are primarily for knowledge acquisition and should complement clinical learning. Classroom learning facilitated consolidation of clinical experiences with expert clinical reasoning. Social aspects of AHDs were highly valued as an important secondary purpose. Perceived effectiveness of teaching and learning: Case-based teaching engaged residents in critical thinking; active learning was valued. Knowledge retention was considered suboptimal. Perspectives on the concept of AHDs as "protected time" varied in the three programs. Findings suggest that (1) engagement in classroom learning occurs through participation in clinically oriented discussions that highlight expert reasoning processes; (2) formal classroom teaching, which focuses on knowledge acquisition, can enhance informal learning occurring during clinical activity; and (3) social aspects of AHDs, including their role in creating communities of practice in residency programs and in professional identity formation, are an important, underappreciated asset for residency programs.

Supervised machine learning algorithms to diagnose stress for vehicle drivers based on physiological sensor signals.

PubMed

Barua, Shaibal; Begum, Shahina; Ahmed, Mobyen Uddin

2015-01-01

Machine learning algorithms play an important role in computer science research. Recent advancement in sensor data collection in clinical sciences lead to a complex, heterogeneous data processing, and analysis for patient diagnosis and prognosis. Diagnosis and treatment of patients based on manual analysis of these sensor data are difficult and time consuming. Therefore, development of Knowledge-based systems to support clinicians in decision-making is important. However, it is necessary to perform experimental work to compare performances of different machine learning methods to help to select appropriate method for a specific characteristic of data sets. This paper compares classification performance of three popular machine learning methods i.e., case-based reasoning, neutral networks and support vector machine to diagnose stress of vehicle drivers using finger temperature and heart rate variability. The experimental results show that case-based reasoning outperforms other two methods in terms of classification accuracy. Case-based reasoning has achieved 80% and 86% accuracy to classify stress using finger temperature and heart rate variability. On contrary, both neural network and support vector machine have achieved less than 80% accuracy by using both physiological signals.

Clinical inertia, uncertainty and individualized guidelines.

PubMed

Reach, G

2014-09-01

Doctors often do not follow the guidelines of good practice based on evidence-based medicine, and this "clinical inertia" may represent an impediment to efficient care. The aims of this article are as follows: 1) to demonstrate that this phenomenon is often the consequence of a discrepancy between the technical rationality of evidence-based medicine and the modes of reasoning of physicians practiced in "real-life", which is marked by uncertainty and risk; 2) to investigate in this context the meaning of the recent, somewhat paradoxical, concept of "individualized guidelines"; and 3) to revisit the real, essentially pedagogical, place of guidelines in medical practice. Copyright © 2014. Published by Elsevier Masson SAS.

Feedback in formative OSCEs: comparison between direct observation and video-based formats

PubMed Central

Junod Perron, Noëlle; Louis-Simonet, Martine; Cerutti, Bernard; Pfarrwaller, Eva; Sommer, Johanna; Nendaz, Mathieu

2016-01-01

Introduction Medical students at the Faculty of Medicine, University of Geneva, Switzerland, have the opportunity to practice clinical skills with simulated patients during formative sessions in preparation for clerkships. These sessions are given in two formats: 1) direct observation of an encounter followed by verbal feedback (direct feedback) and 2) subsequent review of the videotaped encounter by both student and supervisor (video-based feedback). The aim of the study was to evaluate whether content and process of feedback differed between both formats. Methods In 2013, all second- and third-year medical students and clinical supervisors involved in formative sessions were asked to take part in the study. A sample of audiotaped feedback sessions involving supervisors who gave feedback in both formats were analyzed (content and process of the feedback) using a 21-item feedback scale. Results Forty-eight audiotaped feedback sessions involving 12 supervisors were analyzed (2 direct and 2 video-based sessions per supervisor). When adjusted for the length of feedback, there were significant differences in terms of content and process between both formats; the number of communication skills and clinical reasoning items addressed were higher in the video-based format (11.29 vs. 7.71, p=0.002 and 3.71 vs. 2.04, p=0.010, respectively). Supervisors engaged students more actively during the video-based sessions than during direct feedback sessions (self-assessment: 4.00 vs. 3.17, p=0.007; active problem-solving: 3.92 vs. 3.42, p=0.009). Students made similar observations and tended to consider that the video feedback was more useful for improving some clinical skills. Conclusion Video-based feedback facilitates discussion of clinical reasoning, communication, and professionalism issues while at the same time actively engaging students. Different time and conceptual frameworks may explain observed differences. The choice of feedback format should depend on the educational goal. PMID:27834170

Feedback in formative OSCEs: comparison between direct observation and video-based formats.

PubMed

Junod Perron, Noëlle; Louis-Simonet, Martine; Cerutti, Bernard; Pfarrwaller, Eva; Sommer, Johanna; Nendaz, Mathieu

2016-01-01

Medical students at the Faculty of Medicine, University of Geneva, Switzerland, have the opportunity to practice clinical skills with simulated patients during formative sessions in preparation for clerkships. These sessions are given in two formats: 1) direct observation of an encounter followed by verbal feedback (direct feedback) and 2) subsequent review of the videotaped encounter by both student and supervisor (video-based feedback). The aim of the study was to evaluate whether content and process of feedback differed between both formats. In 2013, all second- and third-year medical students and clinical supervisors involved in formative sessions were asked to take part in the study. A sample of audiotaped feedback sessions involving supervisors who gave feedback in both formats were analyzed (content and process of the feedback) using a 21-item feedback scale. Forty-eight audiotaped feedback sessions involving 12 supervisors were analyzed (2 direct and 2 video-based sessions per supervisor). When adjusted for the length of feedback, there were significant differences in terms of content and process between both formats; the number of communication skills and clinical reasoning items addressed were higher in the video-based format (11.29 vs. 7.71, p= 0.002 and 3.71 vs. 2.04, p= 0.010, respectively). Supervisors engaged students more actively during the video-based sessions than during direct feedback sessions (self-assessment: 4.00 vs. 3.17, p= 0.007; active problem-solving: 3.92 vs. 3.42, p= 0.009). Students made similar observations and tended to consider that the video feedback was more useful for improving some clinical skills. Video-based feedback facilitates discussion of clinical reasoning, communication, and professionalism issues while at the same time actively engaging students. Different time and conceptual frameworks may explain observed differences. The choice of feedback format should depend on the educational goal.

42 CFR 409.44 - Skilled services requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... services requirements. (a) General. The intermediary's decision on whether care is reasonable and necessary... is based upon objective clinical evidence regarding the beneficiary's individual need for care. (b... performed by a registered nurse, or practical (vocational) nurse, as defined in § 484.4 of this chapter...

Thinking about thinking: implications for patient safety.

PubMed

Montgomery, Kathryn

2009-01-01

Clinical medicine, a learned, rational, science-using practice, is labelled a science even though physicians have the good sense not to practise it that way. Rather than thinking like scientists - or how we think scientists think - physicians are engaged in analogical, interpretive reasoning that resembles Aristotle's phronesis, or practical reasoning, more closely than episteme, or scientific reasoning. In medicine, phronesis is clinical judgment; and while it depends on both a fund of information and extensive experience, somehow it is not quite teachable. This practical, clinical rationality relies on case narrative for teaching and learning about illness and disease, for recording and communicating about patient care and, inevitably, for thinking about and remembering the details, as well as the overarching rules of practice. At the same time, "anecdotal" remains the most pejorative word in medicine, and the tension between the justifiable caution this disdain expresses and the pervasive narrative structure of medical knowledge is characteristic of clinical knowing generally: a tug-of-war between apparent irreconcilables that can be settled only by an appeal to the circumstances of the clinical situation. Practical rationality in the clinical encounter is characterized by a productive circulation between the particular details of the patient's presentation and general information about disease stored as a taxonomy of cases. Evidence-based medicine can improve this negotiation between general knowledge and the patient's particulars, but it cannot replace it. In a scientific era, clinical judgment remains the quintessential intellectual strength of the clinician. Why, then, do we not teach the epistemology of medicine? Understanding the mis-description of physicians' thinking - and the accompanying claim that medicine is, in itself, a science - could mitigate the misplaced perfectionism that makes mistakes in medicine personal and unthinkable.

Training in neurology.

PubMed

Aminoff, Michael J

2008-05-13

The training of clinical neurologists is undergoing profound change. Increasing subspecialization within neurology, the widening separation of clinical neurology from other branches of internal medicine, limitations of exposure to training in internal medicine, mandated restrictions in working hours, and attempts to shorten the training period are likely to have adverse effects on the next generation of clinical neurologists. Despite the need for a broad base in general medicine, discussed here, the exposure of neurology trainees to general medical disorders is diminishing. An emphasis on an algorithmic approach to patient management rather than on educating residents to use their reasoning faculties when applying new techniques and knowledge to clinical practice may adversely affect patient care. Neurologists require broad-based training in neurology, internal medicine, and psychiatry, to ensure excellence in clinical practice. It is time to question again whether they are receiving the training that they need.

Chinese Herbal Medicine for Functional Abdominal Pain Syndrome: From Clinical Findings to Basic Understandings

PubMed Central

Liu, Tao; Wang, Ning

2016-01-01

Functional abdominal pain syndrome (FAPS) is one of the less common functional gastrointestinal disorders. Conventional therapy has unsatisfactory response to it so people turn to Chinese medicine for help. Currently, we reviewed the whole picture of Chinese herbal medicine (CHM) clinical and basic application in the treatment of FAPS, especially the traditional Chinese medicine (TCM) syndrome, the single herb, and Chinese medicine formulae, thus to provide a solid base to further develop evidence-based study for this common gastrointestinal complaint in the future. We developed the search strategy and set the inclusion and exclusion criteria for article search. From the included articles, we totally retrieved 586 records according to our searching criteria, of which 16 were duplicate records and 291 were excluded for reasons of irrelevance. The full text of 279 articles was retrieved for detailed assessment, of which 123 were excluded for various reasons. The number one used single herb is Radix Ginseng. The most common syndrome was liver qi depression. The most frequently used classic formula was Si-Mo-Tang. This reflected the true situation of clinical practice of Chinese medicine practitioners and could be further systematically synthesized as key points of the therapeutic research for FAPS. PMID:27366194

Chinese Herbal Medicine for Functional Abdominal Pain Syndrome: From Clinical Findings to Basic Understandings.

PubMed

Liu, Tao; Wang, Ning; Zhang, Li; Zhong, Linda

2016-01-01

Functional abdominal pain syndrome (FAPS) is one of the less common functional gastrointestinal disorders. Conventional therapy has unsatisfactory response to it so people turn to Chinese medicine for help. Currently, we reviewed the whole picture of Chinese herbal medicine (CHM) clinical and basic application in the treatment of FAPS, especially the traditional Chinese medicine (TCM) syndrome, the single herb, and Chinese medicine formulae, thus to provide a solid base to further develop evidence-based study for this common gastrointestinal complaint in the future. We developed the search strategy and set the inclusion and exclusion criteria for article search. From the included articles, we totally retrieved 586 records according to our searching criteria, of which 16 were duplicate records and 291 were excluded for reasons of irrelevance. The full text of 279 articles was retrieved for detailed assessment, of which 123 were excluded for various reasons. The number one used single herb is Radix Ginseng. The most common syndrome was liver qi depression. The most frequently used classic formula was Si-Mo-Tang. This reflected the true situation of clinical practice of Chinese medicine practitioners and could be further systematically synthesized as key points of the therapeutic research for FAPS.

A Knowledge-based System for Intelligent Support in Pharmacogenomics Evidence Assessment: Ontology-driven Evidence Representation and Retrieval.

PubMed

Lee, Chia-Ju; Devine, Beth; Tarczy-Hornoch, Peter

2017-01-01

Pharmacogenomics holds promise as a critical component of precision medicine. Yet, the use of pharmacogenomics in routine clinical care is minimal, partly due to the lack of efficient and effective use of existing evidence. This paper describes the design, development, implementation and evaluation of a knowledge-based system that fulfills three critical features: a) providing clinically relevant evidence, b) applying an evidence-based approach, and c) using semantically computable formalism, to facilitate efficient evidence assessment to support timely decisions on adoption of pharmacogenomics in clinical care. To illustrate functionality, the system was piloted in the context of clopidogrel and warfarin pharmacogenomics. In contrast to existing pharmacogenomics knowledge bases, the developed system is the first to exploit the expressivity and reasoning power of logic-based representation formalism to enable unambiguous expression and automatic retrieval of pharmacogenomics evidence to support systematic review with meta-analysis.

Organization and management of community-based dental education programs: an overview from the dental Pipeline program.

PubMed

Bailit, Howard L

2010-10-01

Disparities in access to dental care are a major problem in the United States. Effectively run community-based dental education programs can make a significant contribution to reducing access disparities and at the same time enrich the educational experiences of dental students and residents. For complex historical reasons, dental schools did not base their clinical training programs in community hospitals and clinics like the other health professions. Now, because of trends in school finances, changes in societal values, and limitations in current educational experiences, schools are increasing the time students spend in community clinics. This is likely to continue. The chapters in the first section of the report on the Pipeline, Profession, and Practice: Community-Based Dental Education program--for which this chapter serves as an introduction-provide detailed information on the operation of community-based education programs.

Improving the Clinical Skills Performance of Graduating Medical Students Using “WISE OnCall,” a Multimedia Educational Module

PubMed Central

Szyld, Demian; Uquillas, Kristen; Green, Brad R.; Yavner, Steven D.; Song, Hyuksoon; Nick, Michael W.; Ng, Grace M.; Pusic, Martin V.; Riles, Thomas S.; Kalet, Adina

2017-01-01

Introduction “Transitions to residency” programs are designed to maximize quality and safety of patient care, as medical students become residents. However, best instructional or readiness assessment practices are not yet established. We sought to study the impact of a screen-based interactive curriculum designed to prepare interns to address common clinical coverage issues (WISE OnCall) on the clinical skills demonstrated in simulation and hypothesize that performance would improve after completing the module. Methods Senior medical students were recruited to participate in this single group prestudy/poststudy. Students responded to a call from a standardized nurse (SN) and assessed a standardized patient (SP) with low urine output, interacted with a 45-minute WISE OnCall module on the assessment and management of oliguria, and then evaluated a different SP with low urine output of a different underlying cause. Standardized patients assessed clinical skills with a 37-item, behaviorally anchored checklist measuring clinical skills (intraclass correlation coefficient [ICC], 0.55–0.81). Standardized nurses rated care quality and safety and collaboration and interprofessional communication using a 33-item literature-based, anchored checklist (ICC, 0.47–0.52). Standardized patient and SN ratings of the same student performance were correlated (r, 0.37–0.62; P < 0.01). Physicians assessed clinical reasoning quality based on the students’ patient encounter note (ICC, 0.55–0.68), ratings that did not correlate with SP and SN ratings. We compared pre-post clinical skills performance and clinical reasoning. Fifty-two medical students (31%) completed this institutional review board –approved study. Results Performance as measured by the SPs, SNs, and the postencounter note all showed improvement with mostly moderate to large effect sizes (range of Cohen’s d, 0.30–1.88; P < 0.05) after completion of the online module. Unexpectedly, professionalism as rated by the SP was poorer after the module (Cohen’s d, −0.93; P = 0.000). Discussion A brief computer-based educational intervention significantly improved graduating medical students' clinical skills needed to be ready for residency. PMID:29076970

Teaching Medical Students the Important Connection between Communication and Clinical Reasoning

PubMed Central

Windish, Donna M; Price, Eboni G; Clever, Sarah L; Magaziner, Jeffrey L; Thomas, Patricia A

2005-01-01

Background Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care. Objective To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice. Design In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process. Participants Second-year medical students. Measurements All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion. Results Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing ≥1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important. Conclusions Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training. PMID:16423099

Ethical case deliberation and decision making.

PubMed

Gracia, Diego

2003-01-01

During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics.

Clinical Reasoning in the Assessment and Planning for Intervention for Oppositional Defiant Disorder

ERIC Educational Resources Information Center

Wilcox, Gabrielle; Heudes, Alethea

2017-01-01

Clinical reasoning requires thoughtful consideration of a variety of factors that contribute to the conceptualization of a case such as the reason for referral, school information, home environment, assessment outcomes, and behavioural observations made during assessments. The purpose of this article is to provide the reader with insight into the…

Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines.

PubMed

Bonilauri Ferreira, Ana Paula Ribeiro; Ferreira, Rodrigo Fernando; Rajgor, Dimple; Shah, Jatin; Menezes, Andrea; Pietrobon, Ricardo

2010-04-20

Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. FOUR MAIN THEMES WERE IDENTIFIED: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.

Correlation between the reason for referral, clinical, and objective assessment of the risk for dysphagia.

PubMed

Mancopes, Renata; Gonçalves, Bruna Franciele da Trindade; Costa, Cintia Conceição; Favero, Talita Cristina; Drozdz, Daniela Rejane Constantino; Bilheri, Diego Fernando Dorneles; Schumacher, Stéfani Fernanda

2014-01-01

To correlate the reason for referral to speech therapy service at a university hospital with the results of clinical and objective assessment of risk for dysphagia. This is a cross-sectional, observational, retrospective analytical and quantitative study. The data were gathered from the database, and the information used was the reason for referral to speech therapy service, results of clinical assessment of the risk for dysphagia, and also from swallowing videofluoroscopy. There was a mean difference between the variables of the reason for the referral, results of the clinical and objective swallowing assessments, and scale of penetration/aspiration, although the values were not statistically significant. Statistically significant correlation was observed between clinical and objective assessments and the penetration scale, with the largest occurring between the results of objective assessment and penetration scale. There was a correlation between clinical and objective assessments of swallowing and mean difference between the variables of the reason for the referral with their respective assessment. This shows the importance of the association between the data of patient's history and results of clinical evaluation and complementary tests, such as videofluoroscopy, for correct identification of the swallowing disorders, being important to combine the use of severity scales of penetration/aspiration for diagnosis.

Clinical Reasoning in the Real World Is Mediated by Bounded Rationality: Implications for Diagnostic Clinical Practice Guidelines

PubMed Central

Bonilauri Ferreira, Ana Paula Ribeiro; Ferreira, Rodrigo Fernando; Rajgor, Dimple; Shah, Jatin; Menezes, Andrea; Pietrobon, Ricardo

2010-01-01

Background Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. Method This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. Results Four main themes were identified: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. Discussion Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration. PMID:20421920

Accounting for dropout reason in longitudinal studies with nonignorable dropout.

PubMed

Moore, Camille M; MaWhinney, Samantha; Forster, Jeri E; Carlson, Nichole E; Allshouse, Amanda; Wang, Xinshuo; Routy, Jean-Pierre; Conway, Brian; Connick, Elizabeth

2017-08-01

Dropout is a common problem in longitudinal cohort studies and clinical trials, often raising concerns of nonignorable dropout. Selection, frailty, and mixture models have been proposed to account for potentially nonignorable missingness by relating the longitudinal outcome to time of dropout. In addition, many longitudinal studies encounter multiple types of missing data or reasons for dropout, such as loss to follow-up, disease progression, treatment modifications and death. When clinically distinct dropout reasons are present, it may be preferable to control for both dropout reason and time to gain additional clinical insights. This may be especially interesting when the dropout reason and dropout times differ by the primary exposure variable. We extend a semi-parametric varying-coefficient method for nonignorable dropout to accommodate dropout reason. We apply our method to untreated HIV-infected subjects recruited to the Acute Infection and Early Disease Research Program HIV cohort and compare longitudinal CD4 + T cell count in injection drug users to nonusers with two dropout reasons: anti-retroviral treatment initiation and loss to follow-up.

Becoming a teacher of clinical reasoning.

PubMed

Trowbridge, Robert L; Olson, Andrew P J

2018-03-28

Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators' limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.

Voluntary attendance of small-group brainstorming tutoring courses intensify new clerk's "excellence in clinical care": a pilot study.

PubMed

Yang, Ling-Yu; Huang, Chia-Chang; Hsu, Hui-Chi; Yang, Ying-Ying; Chang, Ching-Chi; Chuang, Chiao-Lin; Lee, Wei-Shin; Liang, Jen-Feng; Cheng, Hao Min; Huang, Chin-Chou; Lee, Fa-Yauh; Ho, Shung-Tai; Kirby, Ralph

2017-01-06

Clerkship provides a unique way of transferring the knowledge and skills gathered during medical school's curriculum into real-ward clinical care environment. The annual program evaluation has indicated that the training of clerks in diagnostic and clinical reasoning skills needed to be enhanced. Recently, "clinical excellence" program have been promoted in our institution to augment the excellence in clinical care of new clerks. Current study aims to evaluate whether this pilot program improve the "clinical excellence" of new clerks. In a pilot study, groups of new clerks in years 2013 and 2014 voluntarily attended either a small-group brainstorming course or a didactic classroom tutoring courses as part of their 3-month internal medicine clinical rotation block. A third group of new clerks did not join either of the above courses and this group served as the control group. Pre-block/post-block self-assessment and post-block 5-station mini-Objective Subjective Clinical Examinations (OSCEs) were used to evaluate the effectiveness of these two additional courses that trained diagnostic and clinical reasoning skills. Overtime, the percentages of new clerks that attended voluntarily either the small-group brainstorming or classroom tutoring courses were increased. Higher post-block self-assessed diagnostic and clinical reasoning skill scores were found among individuals who attended the small-group brainstorming courses compared to either the didactic group or the control group. In a corresponding manner, the small-group brainstorming group obtained higher summary OSCE diag and OSCE reason scores than either the didactic group or control group. For all basic images/laboratory OSCE stations, the individual diagnostic skill (OSCE diag ) scores of the small-group brainstorming group were higher than those of the didactic group. By way of contrast, only the clinical reasoning skill (OSCE reason ) scores of the basic electrocardiogram and complete blood count + biochemistry OSCE station of thesmall-group brainstorming group were higher than those of the didactic group. Among the small-group brainstorming group, clerks with higher cumulative learning hours (>30-h) had significant higher OSCE diag and OSCE reason scores (>400) than those with less cumulative learning hours. Our pilot study provides a successful example of the use of a small-group tutoring courses for augmenting the diagnostic and clinical reasoning skills of new clerks. The positive results obtained during the initial 2-year long pilot "clinical excellence" program have encouraged the formal implementation of this course as part of the clerkship curriculum.

Finding clusters of similar events within clinical incident reports: a novel methodology combining case based reasoning and information retrieval

PubMed Central

Tsatsoulis, C; Amthauer, H

2003-01-01

A novel methodological approach for identifying clusters of similar medical incidents by analyzing large databases of incident reports is described. The discovery of similar events allows the identification of patterns and trends, and makes possible the prediction of future events and the establishment of barriers and best practices. Two techniques from the fields of information science and artificial intelligence have been integrated—namely, case based reasoning and information retrieval—and very good clustering accuracies have been achieved on a test data set of incident reports from transfusion medicine. This work suggests that clustering should integrate the features of an incident captured in traditional form based records together with the detailed information found in the narrative included in event reports. PMID:14645892

Neural bases of motivated reasoning: an FMRI study of emotional constraints on partisan political judgment in the 2004 U.S. Presidential election.

PubMed

Westen, Drew; Blagov, Pavel S; Harenski, Keith; Kilts, Clint; Hamann, Stephan

2006-11-01

Research on political judgment and decision-making has converged with decades of research in clinical and social psychology suggesting the ubiquity of emotion-biased motivated reasoning. Motivated reasoning is a form of implicit emotion regulation in which the brain converges on judgments that minimize negative and maximize positive affect states associated with threat to or attainment of motives. To what extent motivated reasoning engages neural circuits involved in "cold" reasoning and conscious emotion regulation (e.g., suppression) is, however, unknown. We used functional neuroimaging to study the neural responses of 30 committed partisans during the U.S. Presidential election of 2004. We presented subjects with reasoning tasks involving judgments about information threatening to their own candidate, the opposing candidate, or neutral control targets. Motivated reasoning was associated with activations of the ventromedial prefrontal cortex, anterior cingulate cortex, posterior cingulate cortex, insular cortex, and lateral orbital cortex. As predicted, motivated reasoning was not associated with neural activity in regions previously linked to cold reasoning tasks and conscious (explicit) emotion regulation. The findings provide the first neuroimaging evidence for phenomena variously described as motivated reasoning, implicit emotion regulation, and psychological defense. They suggest that motivated reasoning is qualitatively distinct from reasoning when people do not have a strong emotional stake in the conclusions reached.

Diagnostic reasoning strategies and diagnostic success.

PubMed

Coderre, S; Mandin, H; Harasym, P H; Fick, G H

2003-08-01

Cognitive psychology research supports the notion that experts use mental frameworks or "schemes", both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem-solving strategies and the likelihood of diagnostic success. Think-aloud protocols were collected to determine the diagnostic reasoning used by experts and non-experts when attempting to diagnose clinical presentations in gastroenterology. Using logistic regression analysis, the study found that there is a relationship between diagnostic reasoning strategy and the likelihood of diagnostic success. Compared to hypothetico-deductive reasoning, the odds of diagnostic success were significantly greater when subjects used the diagnostic strategies of pattern recognition and scheme-inductive reasoning. Two other factors emerged as independent determinants of diagnostic success: expertise and clinical presentation. Not surprisingly, experts outperformed novices, while the content area of the clinical cases in each of the four clinical presentations demonstrated varying degrees of difficulty and thus diagnostic success. These findings have significant implications for medical educators. It supports the introduction of "schemes" as a means of enhancing memory organization and improving diagnostic success.

Medical History as an Introduction to Clinical Reasoning.

ERIC Educational Resources Information Center

Maulitz, Russell C.; And Others

1983-01-01

An elective course in the history of medicine focuses on clinical thinking using the case study method. Course goals include: student recognition of clinical reasoning as a historical process; understanding of distinctions between disease categories and etiological frameworks; and different conceptualizations (etiological and syndromic) of…

Integrated Case Learning: Teaching Clinical Reasoning

ERIC Educational Resources Information Center

Radomski, Natalie; Russell, John

2010-01-01

Learning how to "think like doctors" can be difficult for undergraduate medical students in their early clinical years. Our model of collaborative Integrated Case Learning (ICL) and simulated clinical reasoning aims to address these issues. Taking a socio-cultural perspective, this study investigates the reflective learning interactions…

Discordance of physician clinical judgment vs. pneumonia severity index (PSI) score to admit patients with low risk community-acquired pneumonia: a prospective multicenter study.

PubMed

Marcos, Pedro J; Restrepo, Marcos I; González-Barcala, Francisco J; Soni, Nilam J; Vidal, Iria; Sanjuàn, Pilar; Llinares, Diego; Ferreira-Gonzalez, Lucía; Rábade, Carlos; Otero-González, Isabel; Marcos, Pedro; Verea-Hernando, Héctor

2017-06-01

The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP. An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]. One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P<0.005). Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients.

A semantic-web oriented representation of the clinical element model for secondary use of electronic health records data.

PubMed

Tao, Cui; Jiang, Guoqian; Oniki, Thomas A; Freimuth, Robert R; Zhu, Qian; Sharma, Deepak; Pathak, Jyotishman; Huff, Stanley M; Chute, Christopher G

2013-05-01

The clinical element model (CEM) is an information model designed for representing clinical information in electronic health records (EHR) systems across organizations. The current representation of CEMs does not support formal semantic definitions and therefore it is not possible to perform reasoning and consistency checking on derived models. This paper introduces our efforts to represent the CEM specification using the Web Ontology Language (OWL). The CEM-OWL representation connects the CEM content with the Semantic Web environment, which provides authoring, reasoning, and querying tools. This work may also facilitate the harmonization of the CEMs with domain knowledge represented in terminology models as well as other clinical information models such as the openEHR archetype model. We have created the CEM-OWL meta ontology based on the CEM specification. A convertor has been implemented in Java to automatically translate detailed CEMs from XML to OWL. A panel evaluation has been conducted, and the results show that the OWL modeling can faithfully represent the CEM specification and represent patient data.

A semantic-web oriented representation of the clinical element model for secondary use of electronic health records data

PubMed Central

Tao, Cui; Jiang, Guoqian; Oniki, Thomas A; Freimuth, Robert R; Zhu, Qian; Sharma, Deepak; Pathak, Jyotishman; Huff, Stanley M; Chute, Christopher G

2013-01-01

The clinical element model (CEM) is an information model designed for representing clinical information in electronic health records (EHR) systems across organizations. The current representation of CEMs does not support formal semantic definitions and therefore it is not possible to perform reasoning and consistency checking on derived models. This paper introduces our efforts to represent the CEM specification using the Web Ontology Language (OWL). The CEM-OWL representation connects the CEM content with the Semantic Web environment, which provides authoring, reasoning, and querying tools. This work may also facilitate the harmonization of the CEMs with domain knowledge represented in terminology models as well as other clinical information models such as the openEHR archetype model. We have created the CEM-OWL meta ontology based on the CEM specification. A convertor has been implemented in Java to automatically translate detailed CEMs from XML to OWL. A panel evaluation has been conducted, and the results show that the OWL modeling can faithfully represent the CEM specification and represent patient data. PMID:23268487

Excellence in clinical teaching: knowledge transformation and development required.

PubMed

Irby, David M

2014-08-01

Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers. Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development. The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process. © 2014 John Wiley & Sons Ltd.

Contingency Management Approaches for Adolescent Substance Use Disorders

PubMed Central

Stanger, Catherine; Budney, Alan J.

2010-01-01

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations. PMID:20682220

Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study.

PubMed

Sialubanje, Cephas; Massar, Karlijn; Hamer, Davidson H; Ruiter, Robert A C

2015-09-11

Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women's preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia. We conducted ten focus group discussions (n = 100) with women of reproductive age (15-45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored. Our findings show that women's lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them. Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.

Integrating Research Into Clinical Internship Training Bridging the Science/Practice Gap in Pediatric Psychology

PubMed Central

Spirito, Anthony

2012-01-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a “capstone experience”; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the “business of science.” Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists. PMID:22286345

Summative assessment of 5th year medical students’ clinical reasoning by script concordance test: requirements and challenges

PubMed Central

2012-01-01

Background The Script Concordance Test (SCT) has not been reported in summative assessment of students across the multiple domains of a medical curriculum. We report the steps used to build a test for summative assessment in a medical curriculum. Methods A 51 case, 158-question, multidisciplinary paper was constructed to assess clinical reasoning in 5th-year. 10–16 experts in each of 7 discipline-based reference panels answered questions on-line. A multidisciplinary group considered reference panel data and data from a volunteer group of 6th Years, who sat the same test, to determine the passing score for the 5th Years. Results The mean (SD) scores were 63.6 (7.6) and 68.6 (4.8) for the 6th Year (n = 23, alpha = 0.78) and and 5th Year (n = 132, alpha =0.62) groups (p < 0.05), respectively. The passing score was set at 4 SD from the expert mean. Four students failed. Conclusions The SCT may be a useful method to assess clinical reasoning in medical students in multidisciplinary summative assessments. Substantial investment in training of faculty and students and in the development of questions is required. PMID:22571351

Examining the role of self-regulation and emotion in clinical reasoning: Implications for developing expertise.

PubMed

Lajoie, Susanne P; Zheng, Juan; Li, Shan

2018-06-27

This paper explores the role that self-regulation and emotions play in establishing a clinical diagnosis in the context of solving a clinical case in BioWorld, a computer supported learning environment designed for medical students to practice clinical reasoning. Group differences between high and low performers were explored. The results revealed no group differences in overall measures of SRL but high performers spend more time than lows in a subcategory of the reflection phase (reflecting on prioritized evidence and results). A reciprocal role of emotions was demonstrated for clinical reasoning and predicted students' diagnostic performance. High performers showed less negative activating emotions than low performers.

Involving American Indians and medically underserved rural populations in cancer clinical trials.

PubMed

Guadagnolo, B Ashleigh; Petereit, Daniel G; Helbig, Petra; Koop, David; Kussman, Patricia; Fox Dunn, Emily; Patnaik, Asha

2009-12-01

To assess cancer clinical trial recruitment and reasons for nonaccrual among a rural, medically underserved population served by a community-based cancer care center. We prospectively tracked clinical trial enrollment incidence among all new patients presenting at the Rapid City Regional Cancer Care Institute. Evaluating physicians completed questionnaires for each patient regarding clinical trial enrollment status and primary reasons for nonenrollment. Patients who identified as American Indian were referred to a program where patients were assisted in navigating the medical system by trained, culturally competent staff. Between September 2006 and January 2008, 891 new cancer patients were evaluated. Seventy-eight patients (9%; 95% confidence intervals, 7-11%) were enrolled on a clinical treatment trial. For 73% (95% confidence intervals, 69-75%) of patients (646 of 891) lack of relevant protocol availability or protocol inclusion criteria restrictiveness was the reason for nonenrollment. Only 45 (5%; 95% confidence intervals, 4-7%) patients refused enrollment on a trial. Of the 78 enrolled on a trial, 6 (8%; 95% confidence intervals, 3-16%) were American Indian. Three additional American Indian patients were enrolled under a nontreatment cancer control trial, bringing the total percentage enrolled of the 94 American Indians who presented to the clinic to 10% (95% confidence intervals, 5-17%). Eligibility rates were unable to be calculated and cross validation of the number in the cohort via registries or ICD-9 codes was not performed. Clinical trial participation in this medically underserved population was low overall, but approximately 3-fold higher than reported national accrual rates. Lack of availability of protocols for common cancer sites as well as stringent protocol inclusion criteria were the primary obstacles to clinical trial enrollment. Targeted interventions using a Patient Navigation program were used to engage AI patients and may have resulted in higher clinical trial enrollment among this racial/ethnic group.

Involving American Indians and medically underserved rural populations in cancer clinical trials

PubMed Central

Guadagnolo, B Ashleigh; Petereit, Daniel G; Helbig, Petra; Koop, David; Kussman, Patricia; Dunn, Emily Fox; Patnaik, Asha

2010-01-01

Purpose To assess cancer clinical trial recruitment and reasons for nonaccrual among a rural, medically underserved population served by a community-based cancer care center. Methods We prospectively tracked clinical trial enrollment incidence among all new patients presenting at the Rapid City Regional Cancer Care Institute. Evaluating physicians completed questionnaires for each patient regarding clinical trial enrollment status and primary reasons for nonenrollment. Patients who identified as American Indian were referred to a program where patients were assisted in navigating the medical system by trained, culturally competent staff. Results Between September 2006 and January 2008, 891 new cancer patients were evaluated. Seventy-eight patients (9%; 95% confidence intervals, 7–11%) were enrolled on a clinical treatment trial. For 73% (95% confidence intervals, 69–75%) of patients (646 of 891) lack of relevant protocol availability or protocol inclusion criteria restrictiveness was the reason for nonenrollment. Only 45 (5%; 95% confidence intervals, 4–7%) patients refused enrollment on a trial. Of the 78 enrolled on a trial, 6 (8%; 95% confidence intervals, 3–16%) were American Indian. Three additional American Indian patients were enrolled under a nontreatment cancer control trial, bringing the total percentage enrolled of the 94 American Indians who presented to the clinic to 10% (95% confidence intervals, 5–17%). Limitations Eligibility rates were unable to be calculated and cross validation of the number in the cohort via registries or ICD-9 codes was not performed. Conclusion Clinical trial participation in this medically underserved population was low overall, but approximately 3-fold higher than reported national accrual rates. Lack of availability of protocols for common cancer sites as well as stringent protocol inclusion criteria were the primary obstacles to clinical trial enrollment. Targeted interventions using a Patient Navigation program were used to engage AI patients and may have resulted in higher clinical trial enrollment among this racial/ethnic group. PMID:19933720

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

PubMed Central

Pelaccia, Thierry; Tardif, Jacques; Triby, Emmanuel; Charlin, Bernard

2011-01-01

Context Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward. Purpose This paper aims at exploring a comprehensive approach: the “dual-process theory”, a model developed by cognitive psychologists over the last few years. Discussion After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians’ intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed. PMID:21430797

Health Habits of Urban High School Students: Evaluation of School-Based Clinics.

ERIC Educational Resources Information Center

Seybert, Jeffrey A.; And Others

The number and complexity of health issues facing today's adolescents defy reason. Traditional health/sex education programs and those facilitating parent-adolescent communication are inadequate. Information alone, without access to a range of medical services, cannot prevent pregnancy among sexually active adolescents, help already pregnant young…

The Embryology of Gender

ERIC Educational Resources Information Center

Jorge, Juan Carlos

2010-01-01

More than 50 years after the appearance of the term "gender" in the clinical setting, we have yet to uncover the mechanisms and factors that lead to gender identity formation. Based on human embryology principles, the scientific reasoning with regard to the sexual differentiation of the body is erroneously applied to gender identity formation. The…

Learning to reason: a journey of professional socialisation.

PubMed

Ajjawi, Rola; Higgs, Joy

2008-05-01

One of the key attributes that health professional students and new graduates develop during professional socialisation is clinical reasoning ability. Clinical reasoning is a complex skill that is essential for professional practice. There is limited research specifically addressing how physiotherapists learn to reason in the workplace. The research reported in this paper addressed this gap by investigating how experienced physiotherapists learned to reason in daily practice. This learning journey was examined in the context of professional socialisation. A hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated, semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants' learning journeys were diverse, although certain episodes of learning were common or similar. Role models, mentors and colleagues were found to be influential in the development of reasoning. An important implication for the professional socialisation of physiotherapists and other health professionals and for those involved in practice development is the need to recognise and enhance the role of practice communities in the explicit learning of clinical reasoning skills.

Exploring cognitive integration of basic science and its effect on diagnostic reasoning in novices.

PubMed

Lisk, Kristina; Agur, Anne M R; Woods, Nicole N

2016-06-01

Integration of basic and clinical science knowledge is increasingly being recognized as important for practice in the health professions. The concept of 'cognitive integration' places emphasis on the value of basic science in providing critical connections to clinical signs and symptoms while accounting for the fact that clinicians may not spontaneously articulate their use of basic science knowledge in clinical reasoning. In this study we used a diagnostic justification test to explore the impact of integrated basic science instruction on novices' diagnostic reasoning process. Participants were allocated to an integrated basic science or clinical science training group. The integrated basic science group was taught the clinical features along with the underlying causal mechanisms of four musculoskeletal pathologies while the clinical science group was taught only the clinical features. Participants completed a diagnostic accuracy test immediately after initial learning, and one week later a diagnostic accuracy and justification test. The results showed that novices who learned the integrated causal mechanisms had superior diagnostic accuracy and better understanding of the relative importance of key clinical features. These findings further our understanding of cognitive integration by providing evidence of the specific changes in clinical reasoning when basic and clinical sciences are integrated during learning.

Reasoning Processes Used by Paramedics to Solve Clinical Problems

ERIC Educational Resources Information Center

Alexander, Melissa

2009-01-01

The purpose of this exploratory qualitative study was to determine the reasoning processes used by paramedics to solve clinical problems. Existing research documents concern over the accuracy of paramedics' clinical decision-making, but no research was found that examines the cognitive processes by which paramedics make either faulty or accurate…

Patient participation in a clinic-based community pharmacy medication take-back program.

PubMed

Lystlund, Stefanie; Stevens, Eric; Planas, Lourdes G; Marcy, Todd R

2014-01-01

To describe patient interest and involvement in participating in a clinic-based community pharmacy drug take-back program to dispose of unused, unwanted, or expired (UUE) medications and to identify patients' reasons for participating in the program. A convenience sample of patients at the University of Oklahoma Family Medicine Pharmacy was recruited to complete a needs assessment survey regarding interest in drug take-back programs and current practices for handling UUE medications. Participants who purchased a postage-paid drug disposal envelope were asked to complete a program survey identifying sources of UUE medications, experience with drug take-back programs, and reasons for participation. These participants were later contacted for a follow-up telephone survey regarding their experience with the program and medications sent back. 62 needs assessment surveys were collected. 61% of patients reported interest in a drug take-back program. 57% reported having no UUE medications at home. Commonly reported UUE handling practices included disposal in the garbage (53.2%) or sewer (29.0%) and home storage (17.7%). 15 disposal envelopes were sold to 10 participants whose most common reasons for participation included concern about the safety of household members, accidental or intentional ingestion, and environmental impact. For 4 patients who returned a median of 9.5 prescriptions, the most common class of returned drugs was antibiotics (19.0%). Interest in drug take-back programs exists, but awareness and availability of continuous programs is limited. Programs may be more successful if offered at no cost to patients. Future studies are needed on the types of medications sent back and specific reasons for accumulation.

Clinical reasoning and knowledge management in final year medical students: the role of Student-led Grand Rounds.

PubMed

Kandiah, David Arumaisingam

2017-01-01

The development of clinical reasoning and decision-making skills is often limited in medical school curricula. In reality, medical graduates acquire these skills during their first few years of residency. For many, this can be stressful as they may be working under limited supervision as a part of their rotations. Student-led Grand Rounds was developed to transfer both explicit and tacit knowledge to final year medical students. This pilot project was to apply the principles of knowledge management to allow students to be exposed to the reasoning and decision making of common clinical presentations. Student feedback through questionnaires was collated at the end of the program. Based on feedback and focus groups, modifications were made to produce a stable program in subsequent clinical rotations. Formal feedback was collated from all the 76 students who participated in the first year. This represented 100% of the cohort for this clinical school for that year. There was a 100% response rate as the feedback forms were given and collected at the end of the last session per block. The student responses were both in ratings defined in a feedback forms and in written comments. A total of 74 of the 76 students rated the program highly. They enjoyed the nonthreatening interactions. The remaining two students preferred more didactic teaching. This initiative allows an efficient transfer and utilization of knowledge. This could maximize the acquisition of practical knowledge by medical students as they finish their course in the transition to graduate medical practice.

The role of emotions in clinical reasoning and decision making.

PubMed

Marcum, James A

2013-10-01

What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.

Explore Care Pathways of Colorectal Cancer Patients with Social Network Analysis.

PubMed

Huo, Tianyao; George, Thomas J; Guo, Yi; He, Zhe; Prosperi, Mattia; Modave, François; Bian, Jiang

2017-01-01

Patients with colorectal cancer (CRC) often face treatment delays and the exact reasons have not been well studied. This study is to explore clinical workflow patterns for CRC patients using electronic health records (EHR). In particular, we modeled the clinical workflow (provider-provider interactions) of a CRC patient's workup period as a social network, and identified clusters of workflow patterns based on network characteristics. Understanding of these patterns will help guide healthcare policy-making and practice.

Application of evidence-based dentistry: from research to clinical periodontal practice.

PubMed

Kwok, Vivien; Caton, Jack G; Polson, Alan M; Hunter, Paul G

2012-06-01

Dentists need to make daily decisions regarding patient care, and these decisions should essentially be scientifically sound. Evidence-based dentistry is meant to empower clinicians to provide the most contemporary treatment. The benefits of applying the evidence-based method in clinical practice include application of the most updated treatment and stronger reasoning to justify the treatment. A vast amount of information is readily accessible with today's digital technology, and a standardized search protocol can be developed to ensure that a literature search is valid, specific and repeatable. It involves developing a preset question (population, intervention, comparison and outcome; PICO) and search protocol. It is usually used academically to perform commissioned reviews, but it can also be applied to answer simple clinical queries. The scientific evidence thus obtained can then be considered along with patient preferences and values, clinical patient circumstances and the practitioner's experience and judgment in order to make the treatment decision. This paper describes how clinicians can incorporate evidence-based methods into patient care and presents a clinical example to illustrate the process. © 2012 John Wiley & Sons A/S.

Cultural Norms of Clinical Simulation in Undergraduate Nursing Education

PubMed Central

2015-01-01

Simulated practice of clinical skills has occurred in skills laboratories for generations, and there is strong evidence to support high-fidelity clinical simulation as an effective tool for learning performance-based skills. What are less known are the processes within clinical simulation environments that facilitate the learning of socially bound and integrated components of nursing practice. Our purpose in this study was to ethnographically describe the situated learning within a simulation laboratory for baccalaureate nursing students within the western United States. We gathered and analyzed data from observations of simulation sessions as well as interviews with students and faculty to produce a rich contextualization of the relationships, beliefs, practices, environmental factors, and theoretical underpinnings encoded in cultural norms of the students’ situated practice within simulation. Our findings add to the evidence linking learning in simulation to the development of broad practice-based skills and clinical reasoning for undergraduate nursing students. PMID:28462300

A conceptual model for generating and validating in-session clinical judgments

PubMed Central

Jacinto, Sofia B.; Lewis, Cara C.; Braga, João N.; Scott, Kelli

2016-01-01

Objective Little attention has been paid to the nuanced and complex decisions made in the clinical session context and how these decisions influence therapy effectiveness. Despite decades of research on the dual-processing systems, it remains unclear when and how intuitive and analytical reasoning influence the direction of the clinical session. Method This paper puts forth a testable conceptual model, guided by an interdisciplinary integration of the literature, that posits that the clinical session context moderates the use of intuitive versus analytical reasoning. Results A synthesis of studies examining professional best practices in clinical decision-making, empirical evidence from clinical judgment research, and the application of decision science theories indicate that intuitive and analytical reasoning may have profoundly different impacts on clinical practice and outcomes. Conclusions The proposed model is discussed with respect to its implications for clinical practice and future research. PMID:27088962

Reasons for non-adherence to vaccination at mother and child care clinics (MCCs) in Lambaréné, Gabon.

PubMed

Schwarz, Norbert G; Gysels, Marjolein; Pell, Christopher; Gabor, Julian; Schlie, Meike; Issifou, Saadou; Lell, Bertrand; Kremsner, Peter G; Grobusch, Martin P; Pool, Robert

2009-08-27

The aim of this paper is to explore attitudes of mothers towards childhood vaccinations and reasons for non-attendance and non-adherence to mother-child clinics (MCCs). Forty in-depth interviews with mothers of children under 5 years of age revealed positive attitudes towards vaccination that seem at odds with the region's observed low vaccination coverage. Important reasons for MCC non-attendance included distance to the MCC, transport costs, negative experiences at MCCs (such as interactions with unfriendly staff) and mothers' feeling of shame provoked by different, often poverty-associated reasons such as attending the clinic with a dirty or poorly clothed child.

Feedback on students' clinical reasoning skills during fieldwork education

PubMed Central

de Beer, Marianne; Mårtensson, Lena

2015-01-01

Background/aim Feedback on clinical reasoning skills during fieldwork education is regarded as vital in occupational therapy students' professional development. The nature of supervisors' feedback however, could be confirmative and/or corrective and corrective feedback could be with or without suggestions on how to improve. The aim of the study was to evaluate the impact of supervisors' feedback on final-year occupational therapy students' clinical reasoning skills through comparing the nature of feedback with the students' subsequent clinical reasoning ability. Method A mixed-method approach with a convergent parallel design was used combining the collection and analysis of qualitative and quantitative data. From focus groups and interviews with students, data were collected and analysed qualitatively to determine how the students experienced the feedback they received from their supervisors. By quantitatively comparing the final practical exam grades with the nature of the feedback, their fieldwork End-of-Term grades and average academic performance it became possible to merge the results for comparison and interpretation. Results Students' clinical reasoning skills seem to be improved through corrective feedback if accompanied by suggestions on how to improve, irrespective of their average academic performance. Supervisors were inclined to underrate high performing students and overrate lower performing students. Conclusions Students who obtained higher grades in the final practical examinations received more corrective feedback with suggestions on how to improve from their supervisors. Confirmative feedback alone may not be sufficient for improving the clinical reasoning skills of students. PMID:26256854

Certainty, leaps of faith, and tradition: rethinking clinical interventions.

PubMed

Dzurec, L C

1998-12-01

Clinical decision making requires that clinicians think quickly and in ways that will foster optimal, safe client care. Tradition influences clinical decision making, enhancing efficiency of resulting nursing action; however, since many decisions must be based on data that are either uncertain, incomplete, or indirect, clinicians are readily ensnared in processes involving potentially faulty logic associated with tradition. The author addresses the tenacity of tradition and then focuses on three processes--consensus formation, the grounding of certainty in inductive reasoning, and affirming the consequent--that have affected clinical decision making. For some recipients of care, tradition has had a substantial and invalid influence on their ability to access care.

Reflections in the clinical practice.

PubMed

Borrell-Carrió, F; Hernández-Clemente, J C

2014-03-01

The purpose of this article is to analyze some models of expert decision and their impact on the clinical practice. We have analyzed decision-making considering the cognitive aspects (explanatory models, perceptual skills, analysis of the variability of a phenomenon, creating habits and inertia of reasoning and declarative models based on criteria). We have added the importance of emotions in decision making within highly complex situations, such as those occurring within the clinical practice. The quality of the reflective act depends, among other factors, on the ability of metacognition (thinking about what we think). Finally, we propose an educational strategy based on having a task supervisor and rectification scenarios to improve the quality of medical decision making. Copyright © 2013 Elsevier España, S.L. All rights reserved.

PDT in clinics: indications, results, and markets.

PubMed

Patrice, Thierry; Olivier, David; Bourre, Ludovic

2006-01-01

Photodynamic therapy (PDT) is based on the selective light activation of an exogenously given drug to patients. PDT acts mainly on cell membranes either of neovascular endothelial cells or of cancer cells leading to cancer cell death. Six drugs are now marketed based on clinical assays in various indications, which showed a clear cost efficiency as compared to other classical procedures. PDT is easy to handle and can be performed in medical installations fitting the conditions of health care in developing countries. Its cost effectiveness could represent an appropriate solution to the increasing number of cancers of various origin. However despite all the clinical results now available, PDT development remains slow. The reasons for this situation include cost of development, intellectual property, and competition between pharmaceutical companies.

Investigation of the Study Characteristics Affecting Clinical Trial Quality Using the Protocol Deviations Leading to Exclusion of Subjects From the Per Protocol Set Data in Studies for New Drug Application: A Retrospective Analysis.

PubMed

Kohara, Norihito; Kaneko, Masayuki; Narukawa, Mamoru

2018-01-01

The concept of the risk-based approach has been introduced as an effort to secure the quality of clinical trials. In the risk-based approach, identification and evaluation of risk in advance are considered important. For recently completed clinical trials, we investigated the relationship between study characteristics and protocol deviations leading to the exclusion of subjects from Per Protocol Set (PPS) efficacy analysis. New drugs approved in Japan in the fiscal year 2014-2015 were targeted in the research. The reasons for excluding subjects from the PPS efficacy analysis were described in 102 trials out of 492 in the summary of new drug application documents, which was publicly disclosed after the drug's regulatory approval. The author extracted these reasons along with the numbers of the cases and the study characteristics of each clinical trial. Then, the direct comparison, univariate regression analysis, and multivariate regression analysis was carried out based on the exclusion rate. The study characteristics for which exclusion of subjects from the PPS efficacy analysis were frequently observed was multiregional clinical trials in study region; inhalant and external use in administration route; Anti-infective for systemic use; Respiratory system, Dermatologicals, and Nervous system in therapeutic drug under the Anatomical Therapeutic Chemical Classification. In the multivariate regression analysis, the clinical trial variables of inhalant, Respiratory system, or Dermatologicals were selected as study characteristics leading to a higher exclusion rate. The characteristics of the clinical trial that is likely to cause protocol deviations that will affect efficacy analysis were suggested. These studies should be considered for specific attention and priority observation in the trial protocol or its monitoring plan and execution, such as a clear description of inclusion/exclusion criteria in the protocol, development of training materials to site staff, and/or trial subjects as specific risk-alleviating measures.

Evidence-based practice of transfusion medicine: is it possible and what do the words mean?

PubMed

Vamvakas, Eleftherios C

2004-10-01

Evidence-based medicine (EBM) optimizes clinical decision making by dictating that clinical decisions be based on the best available research evidence and by integrating best research evidence with clinical expertise and patient values. Several rankings of the strength of the evidence generated from different types of clinical research designs have been presented, and, in addressing a particular problem, clinicians can base their decision making on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. At a policy level, the concept of EBM would dictate that policy decisions also be made based on the best available research evidence. In transfusion medicine, however, decisions are based on a broader range of inputs, and the criteria for evaluating the efficacy and/or cost-effectiveness of proposed interventions differ from those used in other areas. Reasons why policy decisions are often based on considerations other than the best research evidence include public expectations about transfusion safety and proposals for applying the precautionary principle to transfusion medicine. Using the debate over the appropriateness of introducing universal white-cell reduction as an example, this review describes 2 perspectives for assessing evidence and/or making clinical or policy decisions: the evidence-based approach and the precautionary-principle approach; and also considers whether decisions in transfusion medicine can be truly evidence based.

The Impact of Selected Contextual Factors on Experts' Clinical Reasoning Performance (Does Context Impact Clinical Reasoning Performance in Experts?)

ERIC Educational Resources Information Center

Durning, Steven J.; Artino, Anthony R.; Boulet, John R.; Dorrance, Kevin; van der Vleuten, Cees; Schuwirth, Lambert

2012-01-01

Context specificity, or the variation in a participant's performance from one case, or situation, to the next, is a recognized problem in medical education. However, studies have not explored the potential reasons for context specificity in experts using the lens of situated cognition and cognitive load theories (CLT). Using these theories, we…

Dual processing theory and experts' reasoning: exploring thinking on national multiple-choice questions.

PubMed

Durning, Steven J; Dong, Ting; Artino, Anthony R; van der Vleuten, Cees; Holmboe, Eric; Schuwirth, Lambert

2015-08-01

An ongoing debate exists in the medical education literature regarding the potential benefits of pattern recognition (non-analytic reasoning), actively comparing and contrasting diagnostic options (analytic reasoning) or using a combination approach. Studies have not, however, explicitly explored faculty's thought processes while tackling clinical problems through the lens of dual process theory to inform this debate. Further, these thought processes have not been studied in relation to the difficulty of the task or other potential mediating influences such as personal factors and fatigue, which could also be influenced by personal factors such as sleep deprivation. We therefore sought to determine which reasoning process(es) were used with answering clinically oriented multiple-choice questions (MCQs) and if these processes differed based on the dual process theory characteristics: accuracy, reading time and answering time as well as psychometrically determined item difficulty and sleep deprivation. We performed a think-aloud procedure to explore faculty's thought processes while taking these MCQs, coding think-aloud data based on reasoning process (analytic, nonanalytic, guessing or combination of processes) as well as word count, number of stated concepts, reading time, answering time, and accuracy. We also included questions regarding amount of work in the recent past. We then conducted statistical analyses to examine the associations between these measures such as correlations between frequencies of reasoning processes and item accuracy and difficulty. We also observed the total frequencies of different reasoning processes in the situations of getting answers correctly and incorrectly. Regardless of whether the questions were classified as 'hard' or 'easy', non-analytical reasoning led to the correct answer more often than to an incorrect answer. Significant correlations were found between self-reported recent number of hours worked with think-aloud word count and number of concepts used in the reasoning but not item accuracy. When all MCQs were included, 19 % of the variance of correctness could be explained by the frequency of expression of these three think-aloud processes (analytic, nonanalytic, or combined). We found evidence to support the notion that the difficulty of an item in a test is not a systematic feature of the item itself but is always a result of the interaction between the item and the candidate. Use of analytic reasoning did not appear to improve accuracy. Our data suggest that individuals do not apply either System 1 or System 2 but instead fall along a continuum with some individuals falling at one end of the spectrum.

Phronesis, clinical reasoning, and Pellegrino's philosophy of medicine.

PubMed

Davis, F D

1997-01-01

In terms of Aristotle's intellectual virtues, the process of clinical reasoning and the discipline of clinical medicine are often construed as techne (art), as episteme (science), or as an amalgam or composite of techne and episteme. Although dimensions of process and discipline are appropriately described in these terms, I argue that phronesis (practical reasoning) provides the most compelling paradigm, particularly of the rationality of the physician's knowing and doing in the clinical encounter with the patient. I anchor this argument, moreover, in Pellegrino's philosophy of medicine as a healing relationship, oriented to the end of a right and good healing action for the individual patient.

Autoimmune Encephalitis at the Neurological Intensive Care Unit: Etiologies, Reasons for Admission and Survival.

PubMed

Harutyunyan, Gayane; Hauer, Larissa; Dünser, Martin W; Karamyan, Anush; Moser, Tobias; Pikija, Slaven; Leitinger, Markus; Novak, Helmut F; Trinka, Eugen; Sellner, Johann

2017-08-01

Early recognition and treatment of autoimmune encephalitis (AE) has become an essential issue in clinical practice. However, little is known about patients with deteriorating conditions and the need for intensive care treatment. Here, we aimed to characterize underlying aetiologies, clinical symptoms, reasons for intensive care admission, and mortality of critically ill patients with AE. We conducted a retrospective chart review of all patients with "definite" or "probable" diagnoses of AE treated at our neurological intensive care unit between 2002 and 2015. We collected and analyzed clinical, paraclinical, laboratory findings and assessed the mortality at last follow-up based on patient records. Twenty-seven patients [median age 55 years (range 25-87), male = 16] were included. Thirteen (48%) had "definite" AE. The most common reasons for admission were status epilepticus (7/27, 26%) and delirium (4/27, 15%). One-year survival was 82%, all five deceased were male, and 3 (60%) of them had "probable" disease. The non-survivors (median follow-up 1 year) were more likely to have underlying cancer and higher need for respiratory support compared to the survivors (p < 0.041, and p = 0.004, respectively). Clinical presentations and outcomes in critically ill patients with AE are diverse, and the most common leading cause for intensive care unit admission was status epilepticus. The association of comorbid malignancy and the need for mechanical ventilation with mortality deserves further attention.

The normalization heuristic: an untested hypothesis that may misguide medical decisions.

PubMed

Aberegg, Scott K; O'Brien, James M

2009-06-01

Medical practice is increasingly informed by the evidence from randomized controlled trials. When such evidence is not available, clinical hypotheses based on pathophysiological reasoning and common sense guide clinical decision making. One commonly utilized general clinical hypothesis is the assumption that normalizing abnormal laboratory values and physiological parameters will lead to improved patient outcomes. We refer to the general use of this clinical hypothesis to guide medical therapeutics as the "normalization heuristic". In this paper, we operationally define this heuristic and discuss its limitations as a rule of thumb for clinical decision making. We review historical and contemporaneous examples of normalization practices as empirical evidence for the normalization heuristic and to highlight its frailty as a guide for clinical decision making.

What are they thinking? Facilitating clinical reasoning through longitudinal patient exposure in rural practice.

PubMed

Campbell, David; Walters, Lucie; Couper, Ian; Greacen, Jane

2017-12-01

  This article reports the findings from an international research workshop, held over 2 days in October 2014 in Bairnsdale, Australia, which brought together 19 clinician teachers and medical educators who work in rural primary care. The objectives of the workshop were to clarify and identify the key aspects of the development of clinical reasoning in students and junior doctors, particularly as a result of longitudinal immersion in rural community practice.   Delegates were asked to prepare a 55-word vignette related to their experience of teaching clinical reasoning, and these case studies formed the basis of identification of key issues, further refined via a modified Delphi process.   The workshop identified four key themes: the patient’s story, the learner’s reasoning, the context of learning, and the role of the supervisor. Exposure to undifferentiated patient presentations is increasingly common in medical education, particularly in longitudinal integrated placements.   This research explored clinicians’ perspectives of how students develop their clinical reasoning: by learning from patients, from their supervisors and by understanding the context of their clinical interactions.  .

Reasons behind the participation in biomedical research: a brief review.

PubMed

Dainesi, Sonia Mansoldo; Goldbaum, Moisés

2014-12-01

Clinical research is essential for the advancement of Medicine, especially regarding the development of new drugs. Understanding the reasons behind patients' decision of participating in these studies is critical for the recruitment and retention in the research. To examine the decision-making of participants in biomedical research, taking into account different settings and environments where clinical research is performed. A critical review of the literature was performed through several databases using the keywords: "motivation", "decision", "reason", "biomedical research", "clinical research", "recruitment", "enrollment", "participation", "benefits", "altruism", "decline", "vulnerability" and "ethics", between August and November 2013, in English and in Portuguese. The review pointed out that the reasons can be different according to some characteristics such as the disease being treated, study phase, prognoses and socioeconomic and cultural environment. Access to better health care, personal benefits, financial rewards and altruism are mentioned depending on the circumstances. Finding out more about individuals' reasons for taking part in the research will allow clinical investigators to design studies of greater benefit for the community and will probably help to remove undesirable barriers imposed to participation. Improving the information to health care professionals and patients on the benefits and risks of clinical trials is certainly a good start.

Stress relief or practice development: varied reasons for attending clinical supervision.

PubMed

Koivu, Aija; Saarinen, Pirjo I; Hyrkas, Kristiina

2011-07-01

The aim of the present study was to explore the differences in the uptake of clinical supervision on the medical and surgical units of an acute hospital relating to the nurses' background and perceptions of their work and health. Considering the varied challenges of nursing in different specialities, the reasons for attending clinical supervision may also vary. In 2003, a survey on work and health issues was conducted in a Finnish university hospital with a 3-year follow-up of the uptake of clinical supervision by the respondents. The nurses who subsequently undertook clinical supervision and their peers who decided not to undertake it were compared in five medical (n=96) and nine surgical units (n=232). On the medical units, stress management motivated the uptake of clinical supervision, whereas on the surgical units, reasons relating to practice development predominated. The reasons for attending clinical supervision can be quite different depending on the basic tasks and organizational culture of the hospital unit. If clinical and managerial supervision are meant to support and complement each other, the nurse manager should be involved in discussions about the needs and goals of clinical supervision provided for staff. © 2011 The Authors. Journal compilation © 2011 Blackwell Publishing Ltd.

Evidence based practice in clinical physiotherapy education: a qualitative interpretive description

PubMed Central

2013-01-01

Background Health care undergraduate students are expected to practice evidence-based after they graduate. Previous research indicates that students face several problems with transferring evidence-based practice to real patient situations. Few studies have explored reasons for this. The aim of this study was to explore beliefs, experiences and attitudes related to third year students’ use of evidence-based practice in clinical physiotherapy education among students, clinical instructors and visiting teachers. Methods In total, six focus group interviews were conducted: three with 16 students, two with nine clinical instructors and one with four visiting teachers. In addition, one individual interview and one interview in a pair were conducted with clinical instructors. Interviewing three different participant-categories ensured comparative analysis and enabled us to exploit differences in perspectives and interactions. Interpretive description guided this process. Results Four integrative themes emerged from the analysis: “attempt to apply evidence-based practice”, “novices in clinical practice”, “prioritize practice experience over evidence-based practice” and “lack role models in evidence-based practice”. Students tried to search for research evidence and to apply this knowledge during clinical placements; a behaviour that indicated a positive attitude towards evidence-based practice. At the same time, students were novices and required basic background information more than research information. As novices they tended to lean on their clinical instructors, and were more eager to gain practical experience than practicing evidence-based; a behaviour that clinical instructors and visiting teachers often supported. Students noticed a lack of an EBP culture. Both students and clinical instructors perceived a need for role models in evidence-based practice. Conclusions Clinical instructors are in a position to influence students during clinical education, and thus, important potential role models in evidence-based practice. Actions from academic and clinical settings are needed to improve competence in evidence-based practice among clinical instructors, and future research is needed to investigate the effect of such efforts on students’ behaviour. PMID:23578211

Evidence based practice in clinical physiotherapy education: a qualitative interpretive description.

PubMed

Olsen, Nina R; Bradley, Peter; Lomborg, Kirsten; Nortvedt, Monica W

2013-04-11

Health care undergraduate students are expected to practice evidence-based after they graduate. Previous research indicates that students face several problems with transferring evidence-based practice to real patient situations. Few studies have explored reasons for this. The aim of this study was to explore beliefs, experiences and attitudes related to third year students' use of evidence-based practice in clinical physiotherapy education among students, clinical instructors and visiting teachers. In total, six focus group interviews were conducted: three with 16 students, two with nine clinical instructors and one with four visiting teachers. In addition, one individual interview and one interview in a pair were conducted with clinical instructors. Interviewing three different participant-categories ensured comparative analysis and enabled us to exploit differences in perspectives and interactions. Interpretive description guided this process. Four integrative themes emerged from the analysis: "attempt to apply evidence-based practice", "novices in clinical practice", "prioritize practice experience over evidence-based practice" and "lack role models in evidence-based practice". Students tried to search for research evidence and to apply this knowledge during clinical placements; a behaviour that indicated a positive attitude towards evidence-based practice. At the same time, students were novices and required basic background information more than research information. As novices they tended to lean on their clinical instructors, and were more eager to gain practical experience than practicing evidence-based; a behaviour that clinical instructors and visiting teachers often supported. Students noticed a lack of an EBP culture. Both students and clinical instructors perceived a need for role models in evidence-based practice. Clinical instructors are in a position to influence students during clinical education, and thus, important potential role models in evidence-based practice. Actions from academic and clinical settings are needed to improve competence in evidence-based practice among clinical instructors, and future research is needed to investigate the effect of such efforts on students' behaviour.

Are medical students being taught anatomy in a way that best prepares them to be a physician?

PubMed

Meral Savran, Mona; Tranum-Jensen, Jørgen; Frost Clementsen, Paul; Hastrup Svendsen, Jesper; Holst Pedersen, Jesper; Seier Poulsen, Steen; Arendrup, Henrik; Konge, Lars

2015-07-01

Reasoning in a clinical context is an attribute of medical expertise. Clinical reasoning in medical school can be encouraged by teaching basic science with a clinical emphasis. The aim of this study was to investigate whether anatomy is being taught in a way that facilitates the development of clinical reasoning. Two multiple-choice tests on thoracic anatomy were developed using a modified Delphi approach with groups of four clinical consultants and four teachers, respectively, expressing their opinions about knowledge relevant to thoracic anatomy. Validity was assessed by administering the tests to clinical consultants, anatomy teachers, and pre-course medical students. Post-course medical students took both tests to explore the focus of the course, i.e., whether it facilitated clinical reasoning. The pre-course students scored significantly lower than the teachers and post-course students on both tests and lower than the consultants on the consultants' test (P < 0.001 for all comparisons). The teachers significantly outperformed the consultants (P = 0.03 on the consultants' test, P < 0.001 on the teachers' test) and the medical students (P < 0.001 on both tests). The post-course students scored significantly lower on the consultants' test (P = 0.001) and significantly higher on the teachers' test (P = 0.02) than the consultants. This study demonstrates poor performances by medical students on a test containing clinically relevant anatomy, implying that the teaching they have received has not encouraged clinical reasoning. © 2015 Wiley Periodicals, Inc.

Exploring how students think: a new method combining think-aloud and concept mapping protocols.

PubMed

Pottier, Pierre; Hardouin, Jean-Benoit; Hodges, Brian D; Pistorius, Marc-Antoine; Connault, Jérome; Durant, Cécile; Clairand, Renaud; Sebille, Véronique; Barrier, Jacques-Henri; Planchon, Bernard

2010-09-01

A key element of medical competence is problem solving. Previous work has shown that doctors use inductive reasoning to progress from facts to hypotheses and deductive reasoning to move from hypotheses to the gathering of confirmatory information. No individual assessment method has been designed to quantify the use of inductive and deductive procedures within clinical reasoning. The aim of this study was to explore the feasibility and reliability of a new method which allows for the rapid identification of the style (inductive or deductive) of clinical reasoning in medical students and experts. The study included four groups of four participants. These comprised groups of medical students in Years 3, 4 and 5 and a group of specialists in internal medicine, all at a medical school with a 6-year curriculum in France. Participants were asked to solve four clinical problems by thinking aloud. The thinking expressed aloud was immediately transcribed into concept maps by one or two 'writers' trained to distinguish inductive and deductive links. Reliability was assessed by estimating the inter-writer correlation. The calculated rate of inductive reasoning, the richness score and the rate of exhaustiveness of reasoning were compared according to the level of expertise of the individual and the type of clinical problem. The total number of maps drawn amounted to 32 for students in Year 4, 32 for students in Year 5, 16 for students in Year 3 and 16 for experts. A positive correlation was found between writers (R = 0.66-0.93). Richness scores and rates of exhaustiveness of reasoning did not differ according to expertise level. The rate of inductive reasoning varied as expected according to the nature of the clinical problem and was lower in experts (41% versus 67%). This new method showed good reliability and may be a promising tool for the assessment of medical problem-solving skills, giving teachers a means of diagnosing how their students think when they are confronted with clinical problems.

A Pilot Study of Reasons and Risk Factors for "No-Shows" in a Pediatric Neurology Clinic.

PubMed

Guzek, Lindsay M; Fadel, William F; Golomb, Meredith R

2015-09-01

Missed clinic appointments lead to decreased patient access, worse patient outcomes, and increased healthcare costs. The goal of this pilot study was to identify reasons for and risk factors associated with missed pediatric neurology outpatient appointments ("no-shows"). This was a prospective cohort study of patients scheduled for 1 week of clinic. Data on patient clinical and demographic information were collected by record review; data on reasons for missed appointments were collected by phone interviews. Univariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression to assess risk factors for missed appointments. Fifty-nine (25%) of 236 scheduled patients were no-shows. Scheduling conflicts (25.9%) and forgetting (20.4%) were the most common reasons for missed appointments. When controlling for confounding factors in the logistic regression, Medicaid (odds ratio 2.36), distance from clinic, and time since appointment was scheduled were associated with missed appointments. Further work in this area is needed. © The Author(s) 2014.

Experience with Using Multiple Types of Visual Educational Tools during Problem-Based Learning.

PubMed

Kang, Bong Jin

2012-06-01

This study describes the experience of using multiple types of visual educational tools in the setting of problem-based learning (PBL). The author intends to demonstrate their roles in diverse and efficient ways of clinical reasoning and problem solving. Visual educational tools were introduced in a lecture that included their various types, possible benefits, and some examples. Each group made one mechanistic case diagram per week, and each student designed one diagnostic schema or therapeutic algorithm per week, based on their learning issues. The students were also told to provide commentary, which was intended to give insights into their truthfulness. Subsequently, the author administered a questionnaire about the usefulness and weakness of visual educational tools and the difficulties with performing the work. Also, the qualities of the products were assessed by the author. There were many complaints about the adequacy of the introduction of visual educational tools, also revealed by the many initial inappropriate types of products. However, the exercise presentation in the first week improved the level of understanding regarding their purposes and the method of design. In general, students agreed on the benefits of their help in providing a deep understanding of the cases and the possibility of solving clinical problems efficiently. The commentary was helpful in evaluating the truthfulness of their efforts. Students gave suggestions for increasing the percentage of their scores, considering the efforts. Using multiple types of visual educational tools during PBL can be useful in understanding the diverse routes of clinical reasoning and clinical features.

[Description of the mental processes occurring during clinical reasoning].

PubMed

Pottier, P; Planchon, B

2011-06-01

Clinical reasoning is a highly complex system with multiple inter-dependent mental activities. Gaining a better understanding of those cognitive processes has two practical implications: for physicians, being able to analyse their own reasoning method may prove to be helpful in diagnostic dead end; for medical teachers, identifying problem-solving strategies used by medical students may foster an appropriate individual feed-back aiming at improving their clinical reasoning skills. On the basis of a detailed literature review, the main diagnostic strategies and their related pattern of mental processes are described and illustrated with a concrete example, going from the patient's complaint to the chosen solution. Inductive, abductive and deductive diagnostic approaches are detailed. Different strategies for collecting data (exhaustive or oriented) and for problem-building are described. The place of problem solving strategies such as pattern-recognition, scheme inductive process, using of clinical script, syndrome grouping and mental hypotheses test is considered. This work aims at breaking up mental activities in process within clinical reasoning reminding that expert reasoning is characterised by the ability to use and structure the whole of these activities in a coherent system, using combined strategies in order to guarantee a better accuracy of their diagnosis. Copyright © 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.

Proposal for Development of EBM-CDSS (Evidence-Based Clinical Decision Support System) to Aid Prognostication in Terminally Ill Patients

DTIC Science & Technology

2011-10-01

inconsistency in the representation of the dataset. RST provides a mathematical tool for representing and reasoning about vagueness and inconsistency. Its...use of various mathematical , statistical and soft computing methodologies with the objective of identifying meaningful relationships between condition...Evidence-based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL 2Department of Mathematics , Indiana University Northwest, Gary

Knowledge-based computer systems for radiotherapy planning.

PubMed

Kalet, I J; Paluszynski, W

1990-08-01

Radiation therapy is one of the first areas of clinical medicine to utilize computers in support of routine clinical decision making. The role of the computer has evolved from simple dose calculations to elaborate interactive graphic three-dimensional simulations. These simulations can combine external irradiation from megavoltage photons, electrons, and particle beams with interstitial and intracavitary sources. With the flexibility and power of modern radiotherapy equipment and the ability of computer programs that simulate anything the machinery can do, we now face a challenge to utilize this capability to design more effective radiation treatments. How can we manage the increased complexity of sophisticated treatment planning? A promising approach will be to use artificial intelligence techniques to systematize our present knowledge about design of treatment plans, and to provide a framework for developing new treatment strategies. Far from replacing the physician, physicist, or dosimetrist, artificial intelligence-based software tools can assist the treatment planning team in producing more powerful and effective treatment plans. Research in progress using knowledge-based (AI) programming in treatment planning already has indicated the usefulness of such concepts as rule-based reasoning, hierarchical organization of knowledge, and reasoning from prototypes. Problems to be solved include how to handle continuously varying parameters and how to evaluate plans in order to direct improvements.

Saliva-Based Biosensors: Noninvasive Monitoring Tool for Clinical Diagnostics

PubMed Central

Malon, Radha S. P.; Balakrishnan, Malarvili; Córcoles, Emma P.

2014-01-01

Saliva is increasingly recognised as an attractive diagnostic fluid. The presence of various disease signalling salivary biomarkers that accurately reflect normal and disease states in humans and the sampling benefits compared to blood sampling are some of the reasons for this recognition. This explains the burgeoning research field in assay developments and technological advancements for the detection of various salivary biomarkers to improve clinical diagnosis, management, and treatment. This paper reviews the significance of salivary biomarkers for clinical diagnosis and therapeutic applications, with focus on the technologies and biosensing platforms that have been reported for screening these biomarkers. PMID:25276835

Saliva-based biosensors: noninvasive monitoring tool for clinical diagnostics.

PubMed

Malon, Radha S P; Sadir, Sahba; Balakrishnan, Malarvili; Córcoles, Emma P

2014-01-01

Saliva is increasingly recognised as an attractive diagnostic fluid. The presence of various disease signalling salivary biomarkers that accurately reflect normal and disease states in humans and the sampling benefits compared to blood sampling are some of the reasons for this recognition. This explains the burgeoning research field in assay developments and technological advancements for the detection of various salivary biomarkers to improve clinical diagnosis, management, and treatment. This paper reviews the significance of salivary biomarkers for clinical diagnosis and therapeutic applications, with focus on the technologies and biosensing platforms that have been reported for screening these biomarkers.

Drug addicts seeking treatment after the Iranian Revolution: a clinic-based study.

PubMed

Dalvand, S; Agahi, C; Spencer, C

1984-09-01

A sample survey of 200 addicts attending the Rehabilitation Centre at Shiraz was conducted after the 1979 Iranian Revolution had disrupted both drug supply and addict treatment programmes. The study showed that clinics were, after the revolution, seeing a broader social range of addicts than before; and that action by the authorities was bringing many recently-addicted individuals to clinics. Heroin use predominated among those who were urban residents, whilst villagers were more likely to be opium users. The survey also sought the addicts' perceptions of the reasons for their initiation and addiction.

Evolutions in clinical reasoning assessment: The Evolving Script Concordance Test.

PubMed

Cooke, Suzette; Lemay, Jean-François; Beran, Tanya

2017-08-01

Script concordance testing (SCT) is a method of assessment of clinical reasoning. We developed a new type of SCT case design, the evolving SCT (E-SCT), whereby the patient's clinical story is "evolving" and with thoughtful integration of new information at each stage, decisions related to clinical decision-making become increasingly clear. We aimed to: (1) determine whether an E-SCT could differentiate clinical reasoning ability among junior residents (JR), senior residents (SR), and pediatricians, (2) evaluate the reliability of an E-SCT, and (3) obtain qualitative feedback from participants to help inform the potential acceptability of the E-SCT. A 12-case E-SCT, embedded within a 24-case pediatric SCT (PaedSCT), was administered to 91 pediatric residents (JR: n = 50; SR: n = 41). A total of 21 pediatricians served on the panel of experts (POE). A one-way analysis of variance (ANOVA) was conducted across the levels of experience. Participants' feedback on the E-SCT was obtained with a post-test survey and analyzed using two methods: percentage preference and thematic analysis. Statistical differences existed across levels of training: F = 19.31 (df = 2); p < 0.001. The POE scored higher than SR (mean difference = 10.34; p < 0.001) and JR (mean difference = 16.00; p < 0.001). SR scored higher than JR (mean difference = 5.66; p < 0.001). Reliability (Cronbach's α) was 0.83. Participants found the E-SCT engaging, easy to follow and true to the daily clinical decision-making process. The E-SCT demonstrated very good reliability and was effective in distinguishing clinical reasoning ability across three levels of experience. Participants found the E-SCT engaging and representative of real-life clinical reasoning and decision-making processes. We suggest that further refinement and utilization of the evolving style case will enhance SCT as a robust, engaging, and relevant method for the assessment of clinical reasoning.

A critical narrative review of transfer of basic science knowledge in health professions education.

PubMed

Castillo, Jean-Marie; Park, Yoon Soo; Harris, Ilene; Cheung, Jeffrey J H; Sood, Lonika; Clark, Maureen D; Kulasegaram, Kulamakan; Brydges, Ryan; Norman, Geoffrey; Woods, Nicole

2018-06-01

'Transfer' is the application of a previously learned concept to solve a new problem in another context. Transfer is essential for basic science education because, to be valuable, basic science knowledge must be transferred to clinical problem solving. Therefore, better understanding of interventions that enhance the transfer of basic science knowledge to clinical reasoning is essential. This review systematically identifies interventions described in the health professions education (HPE) literature that document the transfer of basic science knowledge to clinical reasoning, and considers teaching and assessment strategies. A systematic search of the literature was conducted. Articles related to basic science teaching at the undergraduate level in HPE were analysed using a 'transfer out'/'transfer in' conceptual framework. 'Transfer out' refers to the application of knowledge developed in one learning situation to the solving of a new problem. 'Transfer in' refers to the use of previously acquired knowledge to learn from new problems or learning situations. Of 9803 articles initially identified, 627 studies were retrieved for full text evaluation; 15 were included in the literature review. A total of 93% explored 'transfer out' to clinical reasoning and 7% (one article) explored 'transfer in'. Measures of 'transfer out' fostered by basic science knowledge included diagnostic accuracy over time and in new clinical cases. Basic science knowledge supported learning - 'transfer in' - of new related content and ultimately the 'transfer out' to diagnostic reasoning. Successful teaching strategies included the making of connections between basic and clinical sciences, the use of commonsense analogies, and the study of multiple clinical problems in multiple contexts. Performance on recall tests did not reflect the transfer of basic science knowledge to clinical reasoning. Transfer of basic science knowledge to clinical reasoning is an essential component of HPE that requires further development for implementation and scholarship. © 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Describing the clinical reasoning process: application of a model of enablement to a pediatric case.

PubMed

Furze, Jennifer; Nelson, Kelly; O'Hare, Megan; Ortner, Amanda; Threlkeld, A Joseph; Jensen, Gail M

2013-04-01

Clinical reasoning is a core tenet of physical therapy practice leading to optimal patient care. The purpose of this case was to describe the outcomes, subjective experience, and reflective clinical reasoning process for a child with cerebral palsy using the International Classification of Functioning, Disability, and Health (ICF) model. Application of the ICF framework to a 9-year-old boy with spastic triplegic cerebral palsy was utilized to capture the interwoven factors present in this case. Interventions in the pool occurred twice weekly for 1 h over a 10-week period. Immediately post and 4 months post-intervention, the child made functional and meaningful gains. The family unit also developed an enjoyment of exercising together. Each individual family member described psychological, emotional, or physical health improvements. Reflection using the ICF model as a framework to discuss clinical reasoning can highlight important factors contributing to effective patient management.

Simulation and Prediction of the Drug-Drug Interaction Potential of Naloxegol by Physiologically Based Pharmacokinetic Modeling.

PubMed

Zhou, D; Bui, K; Sostek, M; Al-Huniti, N

2016-05-01

Naloxegol, a peripherally acting μ-opioid receptor antagonist for the treatment of opioid-induced constipation, is a substrate for cytochrome P450 (CYP) 3A4/3A5 and the P-glycoprotein (P-gp) transporter. By integrating in silico, preclinical, and clinical pharmacokinetic (PK) findings, minimal and full physiologically based pharmacokinetic (PBPK) models were developed to predict the drug-drug interaction (DDI) potential for naloxegol. The models reasonably predicted the observed changes in naloxegol exposure with ketoconazole (increase of 13.1-fold predicted vs. 12.9-fold observed), diltiazem (increase of 2.8-fold predicted vs. 3.4-fold observed), rifampin (reduction of 76% predicted vs. 89% observed), and quinidine (increase of 1.2-fold predicted vs. 1.4-fold observed). The moderate CYP3A4 inducer efavirenz was predicted to reduce naloxegol exposure by ∼50%, whereas weak CYP3A inhibitors were predicted to minimally affect exposure. In summary, the PBPK models reasonably estimated interactions with various CYP3A modulators and can be used to guide dosing in clinical practice when naloxegol is coadministered with such agents. © 2016 The Authors CPT: Pharmacometrics & Systems Pharmacology published by Wiley Periodicals, Inc. on behalf of American Society for Clinical Pharmacology and Therapeutics.

Clinical examination and management of the dizzy patient.

PubMed

Sandhu, Jaswinder S; Rea, Peter A

2016-12-02

Dizziness is the commonest reason for a GP appointment over the age of 75 years and many dizzy patients will end up in hospital. This article introduces the range of vestibular disorders commonly seen in hospital practice with a symptom-based approach and discusses the range of treatments that might be considered.

Clinical Reasoning in the Assessment and Planning for Intervention for Autism Spectrum Disorder

ERIC Educational Resources Information Center

McCrimmon, Adam W.; Yule, Ashleigh E.

2017-01-01

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder whose incidence is rising. School-based professionals are in an ideal position to provide the much-needed assessment and intervention supports for students with ASD, as the professionals' placement within a formal system affords the opportunity to observe and support children…

[Analysis and prevention of dust pollution caused by 5 common prosthetic materials].

PubMed

Yang, Xiang-Wen; Wei, Bin; Zhu, Cao-Yun; Qian, Liang; Li, Yi-Han

2017-10-01

To analyze and evaluate dust pollution in prosthodontic clinic and make proposal for reasonable protection. This study analyzed the particle size, element composition and dust concentration of 5 materials which were commonly used in dental restorations (veneering ceramics, cobalt-chromium alloy, photosensitive plastic, hard base resin, advanced artificial teeth) by using scanning electron microscopy (SEM), X-ray energy dispersive spectrometer（EDS） and dust concentration laser tester, in order to assess the effects of prosthodontic dust posed on medical staff health and put forward reasonable suggestions for prevention and control of dust pollution. The particle size of veneering ceramics, cobalt-chromium alloy, photosensitive plastic, hard base resin and advanced artificial teeth was (2.15±3.00), (33.78±24.33), (7.78±11.86), (31.16±44.35) and (28.45±39.21)μm, respectively. The time weighted average respirable dust concentration of veneering ceramics was 0.393 mg/m 2 which was beyond the scope of national security. Dust pollution is serious in prosthodontic clinic to which we should pay more attention and take appropriate prevention measures.

The role and position of passive intervertebral motion assessment within clinical reasoning and decision-making in manual physical therapy: a qualitative interview study.

PubMed

van Trijffel, Emiel; Plochg, Thomas; van Hartingsveld, Frank; Lucas, Cees; Oostendorp, Rob A B

2010-06-01

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners' practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.

The role and position of passive intervertebral motion assessment within clinical reasoning and decision-making in manual physical therapy: a qualitative interview study

PubMed Central

van Trijffel, Emiel; Plochg, Thomas; van Hartingsveld, Frank; Lucas, Cees; Oostendorp, Rob A B

2010-01-01

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners’ practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine. PMID:21655394

Wiki Activities in Blended Learning for Health Professional Students: Enhancing Critical Thinking and Clinical Reasoning Skills

ERIC Educational Resources Information Center

Snodgrass, Suzanne

2011-01-01

Health professionals use critical thinking, a key problem solving skill, for clinical reasoning which is defined as the use of knowledge and reflective inquiry to diagnose a clinical problem. Teaching these skills in traditional settings with growing class sizes is challenging, and students increasingly expect learning that is flexible and…

Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation.

PubMed

Tempest, Stephanie; McIntyre, Anne

2006-05-30

The International Classification of Functioning, Disability and Health (ICF) is advocated as a tool to structure rehabilitation and a universal language to aid communication, within the multi-disciplinary team (MDT). The ICF may also facilitate clarification of team roles and clinical reasoning for intervention. This article aims to explore both factors in stroke rehabilitation. Following a review of the literature, a summary was presented and discussed with clinicians working within stroke rehabilitation, to gather expert opinions. The discussions were informal, being part of service development and on-going education. The clinicians summarised key themes for the potential use of the ICF within clinical practice. Two key themes emerged from the literature and expert opinion for the potential use of the ICF in stroke rehabilitation: (i) to aid communication and structure service provision, (ii) to clarify team roles and aid clinical reasoning. Expert opinion was that clarification of team roles needs to occur at a local level due to the skill mix, particular interests, setting and staffing levels within individual teams. The ICF has the potential to demonstrate/facilitate clinical reasoning, especially when different MDT members are working on the same intervention. There is potential for the ICF to be used to clarify team roles and demonstrate clinical reasoning within stroke rehabilitation. Further experiential research is required to substantiate this view.

A structured framework for assessing sensitivity to missing data assumptions in longitudinal clinical trials.

PubMed

Mallinckrodt, C H; Lin, Q; Molenberghs, M

2013-01-01

The objective of this research was to demonstrate a framework for drawing inference from sensitivity analyses of incomplete longitudinal clinical trial data via a re-analysis of data from a confirmatory clinical trial in depression. A likelihood-based approach that assumed missing at random (MAR) was the primary analysis. Robustness to departure from MAR was assessed by comparing the primary result to those from a series of analyses that employed varying missing not at random (MNAR) assumptions (selection models, pattern mixture models and shared parameter models) and to MAR methods that used inclusive models. The key sensitivity analysis used multiple imputation assuming that after dropout the trajectory of drug-treated patients was that of placebo treated patients with a similar outcome history (placebo multiple imputation). This result was used as the worst reasonable case to define the lower limit of plausible values for the treatment contrast. The endpoint contrast from the primary analysis was - 2.79 (p = .013). In placebo multiple imputation, the result was - 2.17. Results from the other sensitivity analyses ranged from - 2.21 to - 3.87 and were symmetrically distributed around the primary result. Hence, no clear evidence of bias from missing not at random data was found. In the worst reasonable case scenario, the treatment effect was 80% of the magnitude of the primary result. Therefore, it was concluded that a treatment effect existed. The structured sensitivity framework of using a worst reasonable case result based on a controlled imputation approach with transparent and debatable assumptions supplemented a series of plausible alternative models under varying assumptions was useful in this specific situation and holds promise as a generally useful framework. Copyright © 2012 John Wiley & Sons, Ltd.

A Logic-Based Psychotherapy Approach to Treating Patients Which Focuses on Faultless Logical Functioning: A Case Study Method

PubMed Central

Almeida, Fernando; Moreira, Diana

2017-01-01

Many clinical patients present to mental health clinics with depressive symptoms, anxiety, psychosomatic complaints, and sleeping problems. These symptoms which originated may originate from marital problems, conflictual interpersonal relationships, problems in securing work, and housing issues, among many others. These issues might interfere which underlie the difficulties that with the ability of the patients face in maintaining faultless logical reasoning (FLR) and faultless logical functioning (FLF). FLR implies to assess correctly premises, rules, and conclusions. And FLF implies assessing not only FLR, but also the circumstances, life experience, personality, events that validate a conclusion. Almost always, the symptomatology is accompanied by intense emotional changes. Clinical experience shows that a logic-based psychotherapy (LBP) approach is not practiced, and that therapists’ resort to psychopharmacotherapy or other types of psychotherapeutic approaches that are not focused on logical reasoning and, especially, logical functioning. Because of this, patients do not learn to overcome their reasoning and functioning errors. The aim of this work was to investigate how LBP works to improve the patients’ ability to think and function in a faultless logical way. This work describes the case studies of three patients. For this purpose we described the treatment of three patients. With this psychotherapeutic approach, patients gain knowledge that can then be applied not only to the issues that led them to the consultation, but also to other problems they have experienced, thus creating a learning experience and helping to prevent such patients from becoming involved in similar problematic situations. This highlights that LBP is a way of treating symptoms that interfere on some level with daily functioning. This psychotherapeutic approach is relevant for improving patients’ quality of life, and it fills a gap in the literature by describing original case analyses. PMID:29312088

Potential bias in the bank: what distinguishes refusers, nonresponders and participants in a clinic-based biobank?

PubMed

Ridgeway, J L; Han, L C; Olson, J E; Lackore, K A; Koenig, B A; Beebe, T J; Ziegenfuss, J Y

2013-01-01

Biobanks are an important resource for genetic and epidemiologic research, but bias may be introduced if those who accept the recruitment invitation differ systematically from those who do not in terms of attributes important to health-related investigations. To understand potential bias in a clinic-based biobank of biological samples, including genetic data linked to electronic health record information, we compared patient characteristics and self-reported information among participants, nonresponders and refusers. We also compared reasons for nonparticipation between refusers and nonresponders to elucidate potential pathways to reduce nonparticipation and any uncovered bias. We mailed recruitment packets to 1,600 adult patients with upcoming appointments at Mayo Clinic (Rochester, Minn., USA) and recorded their participation status. Administrative data were used to compare characteristics across groups. We used phone interviews with 26 nonresponders and 26 refusers to collect self-reported information, including reasons for nonparticipation. Participants were asked to complete a mailed questionnaire. We achieved 26.2% participation (n=419) with 12.1% refusing (n=193) and 61.8% nonresponse (n=988). In multivariate analyses, sex, age, region of residence, and race/ethnicity were significantly associated with participation. The groups differed in information-seeking behaviors and research experience. Refusers more often cited privacy concerns, while nonresponders more often identified time constraints as the reason for nonparticipation. For genomic medicine to advance, large, representative biobanks are required. Significant associations between patient characteristics and nonresponse, as well as systematic differences between refusers and nonresponders, could introduce bias. Oversampling or recruitment changes, including heightened attention to privacy protection and participation burden, may be necessary to increase participation among less-represented groups. Copyright © 2013 S. Karger AG, Basel.

Potential Bias in the Bank: What Distinguishes Refusers, Non-responders and Participants in a Clinic-based Biobank?

PubMed Central

Ridgeway, Jennifer L; Han, Leona C; Olson, Janet E; Lackore, Kandace A; Koenig, Barbara A; Beebe, Timothy J; Ziegenfuss, Jeanette Y

2013-01-01

Background Biobanks are an important resource for genetic and epidemiologic research, but bias may be introduced if those who accept the recruitment invitation differ systematically from those who do not in attributes important to health-related investigations. To understand potential bias in a clinic-based biobank of biological samples, including genetic data linked to Electronic Medical Record information, we compared patient characteristics and self-reported information among participants, non-responders, and refusers. We also compared reasons for non-participation between refusers and non-responders to elucidate potential pathways to reduce non-participation and any uncovered bias. Methods We mailed recruitment packets to 1600 adult patients with upcoming appointments at Mayo Clinic (Rochester, MN) and recorded their participation status. Administrative data were used to compare characteristics across groups. We used phone interviews with 26 non-responders and 26 refusers to collect self-reported information, including reasons for non-participation. Participants were asked to complete a mailed questionnaire. Results We achieved 26.2% participation (n=419) with 12.1% refusing (n=193) and 61.8% non-response (n=988). In multivariate analyses, sex, age, region of residence, and race/ethnicity were significantly associated with participation. The groups differed in information-seeking behaviors and research experience. Refusers more often cited privacy concerns while non-responders more often identified time constraints as the reason for non-participation. Conclusion For genomic medicine to advance, large, representative biobanks are required. Significant associations between patient characteristics and nonresponse, as well as systematic differences between refusers and nonresponders, could introduce bias. Oversampling or recruitment changes, including heightened attention to privacy protection and participation burden, may be necessary to increase participation among less-represented groups. PMID:23595106

EFFECTIVENESS OF PROBLEM BASED LEARNING AS A STRATEGY TO FOSTER PROBLEM SOLVING AND CRITICAL REASONING SKILLS AMONG MEDICAL STUDENTS.

PubMed

Asad, Munazza; Iqbal, Khadija; Sabir, Mohammad

2015-01-01

Problem based learning (PBL) is an instructional approach that utilizes problems or cases as a context for students to acquire problem solving skills. It promotes communication skills, active learning, and critical thinking skills. It encourages peer teaching and active participation in a group. It was a cross-sectional study conducted at Al Nafees Medical College, Isra University, Islamabad, in one month duration. This study was conducted on 193 students of both 1st and 2nd year MBBS. Each PBL consists of three sessions, spaced by 2-3 days. In the first session students were provided a PBL case developed by both basic and clinical science faculty. In Session 2 (group discussion), they share, integrate their knowledge with the group and Wrap up (third session), was concluded at the end. A questionnaire based survey was conducted to find out overall effectiveness of PBL sessions. Teaching through PBLs greatly improved the problem solving and critical reasoning skills with 60% students of first year and 71% of 2nd year agreeing that the acquisition of knowledge and its application in solving multiple choice questions (MCQs) was greatly improved by these sessions. They observed that their self-directed learning, intrinsic motivation and skills to relate basic concepts with clinical reasoning which involves higher order thinking have greatly enhanced. Students found PBLs as an effective strategy to promote teamwork and critical thinking skills. PBL is an effective method to improve critical thinking and problem solving skills among medical students.

A study of optimization techniques in HDR brachytherapy for the prostate

NASA Astrophysics Data System (ADS)

Pokharel, Ghana Shyam

Several studies carried out thus far are in favor of dose escalation to the prostate gland to have better local control of the disease. But optimal way of delivery of higher doses of radiation therapy to the prostate without hurting neighboring critical structures is still debatable. In this study, we proposed that real time high dose rate (HDR) brachytherapy with highly efficient and effective optimization could be an alternative means of precise delivery of such higher doses. This approach of delivery eliminates the critical issues such as treatment setup uncertainties and target localization as in external beam radiation therapy. Likewise, dosimetry in HDR brachytherapy is not influenced by organ edema and potential source migration as in permanent interstitial implants. Moreover, the recent report of radiobiological parameters further strengthen the argument of using hypofractionated HDR brachytherapy for the management of prostate cancer. Firstly, we studied the essential features and requirements of real time HDR brachytherapy treatment planning system. Automating catheter reconstruction with fast editing tools, fast yet accurate dose engine, robust and fast optimization and evaluation engine are some of the essential requirements for such procedures. Moreover, in most of the cases we performed, treatment plan optimization took significant amount of time of overall procedure. So, making treatment plan optimization automatic or semi-automatic with sufficient speed and accuracy was the goal of the remaining part of the project. Secondly, we studied the role of optimization function and constraints in overall quality of optimized plan. We have studied the gradient based deterministic algorithm with dose volume histogram (DVH) and more conventional variance based objective functions for optimization. In this optimization strategy, the relative weight of particular objective in aggregate objective function signifies its importance with respect to other objectives. Based on our study, DVH based objective function performed better than traditional variance based objective function in creating a clinically acceptable plan when executed under identical conditions. Thirdly, we studied the multiobjective optimization strategy using both DVH and variance based objective functions. The optimization strategy was to create several Pareto optimal solutions by scanning the clinically relevant part of the Pareto front. This strategy was adopted to decouple optimization from decision such that user could select final solution from the pool of alternative solutions based on his/her clinical goals. The overall quality of treatment plan improved using this approach compared to traditional class solution approach. In fact, the final optimized plan selected using decision engine with DVH based objective was comparable to typical clinical plan created by an experienced physicist. Next, we studied the hybrid technique comprising both stochastic and deterministic algorithm to optimize both dwell positions and dwell times. The simulated annealing algorithm was used to find optimal catheter distribution and the DVH based algorithm was used to optimize 3D dose distribution for given catheter distribution. This unique treatment planning and optimization tool was capable of producing clinically acceptable highly reproducible treatment plans in clinically reasonable time. As this algorithm was able to create clinically acceptable plans within clinically reasonable time automatically, it is really appealing for real time procedures. Next, we studied the feasibility of multiobjective optimization using evolutionary algorithm for real time HDR brachytherapy for the prostate. The algorithm with properly tuned algorithm specific parameters was able to create clinically acceptable plans within clinically reasonable time. However, the algorithm was let to run just for limited number of generations not considered optimal, in general, for such algorithms. This was done to keep time window desirable for real time procedures. Therefore, it requires further study with improved conditions to realize the full potential of the algorithm.

Where are the history and the physical?

PubMed Central

Bordage, G

1995-01-01

In clinical practice, the history and physical examination are being superseded by laboratory tests and biomedical technology. The author discusses the importance of the clinical examination as the basis for clinical reasoning and of direct observation of students at the patients' bedside in order to assess their diagnostic reasoning. Greater attention to the clinical examination would lead not only to improved clinical skills but also to more cost-effective use of ancillary investigations and, moreover, to a better understanding of the patient by the physician. PMID:7743445

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy.

PubMed

Gao, Shugeng; Zhang, Zhongheng; Brunelli, Alessandro; Chen, Chang; Chen, Chun; Chen, Gang; Chen, Haiquan; Chen, Jin-Shing; Cassivi, Stephen; Chai, Ying; Downs, John B; Fang, Wentao; Fu, Xiangning; Garutti, Martínez I; He, Jianxing; He, Jie; Hu, Jian; Huang, Yunchao; Jiang, Gening; Jiang, Hongjing; Jiang, Zhongmin; Li, Danqing; Li, Gaofeng; Li, Hui; Li, Qiang; Li, Xiaofei; Li, Yin; Li, Zhijun; Liu, Chia-Chuan; Liu, Deruo; Liu, Lunxu; Liu, Yongyi; Ma, Haitao; Mao, Weimin; Mao, Yousheng; Mou, Juwei; Ng, Calvin Sze Hang; Petersen, René H; Qiao, Guibin; Rocco, Gaetano; Ruffini, Erico; Tan, Lijie; Tan, Qunyou; Tong, Tang; Wang, Haidong; Wang, Qun; Wang, Ruwen; Wang, Shumin; Xie, Deyao; Xue, Qi; Xue, Tao; Xu, Lin; Xu, Shidong; Xu, Songtao; Yan, Tiansheng; Yu, Fenglei; Yu, Zhentao; Zhang, Chunfang; Zhang, Lanjun; Zhang, Tao; Zhang, Xun; Zhao, Xiaojing; Zhao, Xuewei; Zhi, Xiuyi; Zhou, Qinghua

2017-09-01

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH 2 O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy

PubMed Central

Zhang, Zhongheng; Brunelli, Alessandro; Chen, Chang; Chen, Chun; Chen, Gang; Chen, Haiquan; Chen, Jin-Shing; Cassivi, Stephen; Chai, Ying; Downs, John B.; Fang, Wentao; Fu, Xiangning; Garutti, Martínez I.; He, Jianxing; Hu, Jian; Huang, Yunchao; Jiang, Gening; Jiang, Hongjing; Jiang, Zhongmin; Li, Danqing; Li, Gaofeng; Li, Hui; Li, Qiang; Li, Xiaofei; Li, Yin; Li, Zhijun; Liu, Chia-Chuan; Liu, Deruo; Liu, Lunxu; Liu, Yongyi; Ma, Haitao; Mao, Weimin; Mao, Yousheng; Mou, Juwei; Ng, Calvin Sze Hang; Petersen, René H.; Qiao, Guibin; Rocco, Gaetano; Ruffini, Erico; Tan, Lijie; Tan, Qunyou; Tong, Tang; Wang, Haidong; Wang, Qun; Wang, Ruwen; Wang, Shumin; Xie, Deyao; Xue, Qi; Xue, Tao; Xu, Lin; Xu, Shidong; Xu, Songtao; Yan, Tiansheng; Yu, Fenglei; Yu, Zhentao; Zhang, Chunfang; Zhang, Lanjun; Zhang, Tao; Zhang, Xun; Zhao, Xiaojing; Zhao, Xuewei; Zhi, Xiuyi; Zhou, Qinghua

2017-01-01

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50–70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH2O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response. PMID:29221302

Biomedical data mining in clinical routine: expanding the impact of hospital information systems.

PubMed

Müller, Marcel; Markó, Kornel; Daumke, Philipp; Paetzold, Jan; Roesner, Arnold; Klar, Rüdiger

2007-01-01

In this paper we want to describe how the promising technology of biomedical data mining can improve the use of hospital information systems: a large set of unstructured, narrative clinical data from a dermatological university hospital like discharge letters or other dermatological reports were processed through a morpho-semantic text retrieval engine ("MorphoSaurus") and integrated with other clinical data using a web-based interface and brought into daily clinical routine. The user evaluation showed a very high user acceptance - this system seems to meet the clinicians' requirements for a vertical data mining in the electronic patient records. What emerges is the need for integration of biomedical data mining into hospital information systems for clinical, scientific, educational and economic reasons.

[Cannabinoids in multiple sclerosis -- therapeutically reasonable?].

PubMed

Trebst, C; Stangel, M

2005-08-01

For centuries extracts from the Cannabis sativa plant have been used for recreational use and as remedies. Anecdotal reports from patients with multiple sclerosis (MS) experiencing relief of their spasticity and pain after smoking marihuana have prompted discussions about a potential therapeutic application of cannabis preparations in MS. Only recently the first large, multicenter, double-blind, placebo controlled study was conducted evaluating the use of cannabinoids for treatment of spasticity and other symptoms related to MS. Based on this trial and previous uncontrolled observations together with insights from basic research and animal experiments there is reasonable evidence for the therapeutical employment of cannabinoids in the treatment of MS related symptoms. Furthermore, data are arising that cannabinoids have immunomodulatory and neuroprotective properties. However, results from clinical trials do not allow the recommendation for the general use of cannabinoids in MS. This article summarizes the present knowledge of clinical and experimental research regarding the therapeutic potential of cannabinoids for the treatment of MS.

[The concept of "understanding" (Verstehen) in Karl Jaspers].

PubMed

Villareal, Helena; Aragona, Massimiliano

2014-01-01

This article explores the relationship between empathy and psychopathology. It deals with the concept of "understanding" in Jaspers' General Psychopathology, 100 years after the publication of its first edition. The Jaspersian proposal has the person and his/her experience as its primary object of study, just as in Ortegas' vital reason. Jaspers' understanding is not rational but empathetic, based on the co-presence of emotional content and detailed descriptions. Jaspers' methodology is essentially pluralistic, considering both explanation and understanding, necessary for psychopathology. Despite certain limits, the concept of understanding is the backbone of the psychopathological reasoning, and has proven useful over a century of clinical practice. However, it needs a review covering the recent epistemological and clinical findings. "To be understandable" is a relational property that emerges from a semiotic process. Therefore, an effective psychology should encompass an inter-subjective process, and get away from strict rationalism.

Reflective blogs in clinical education to promote critical thinking in dental hygiene students.

PubMed

Wetmore, Ann O'Kelley; Boyd, Linda D; Bowen, Denise M; Pattillo, Robin E

2010-12-01

One challenge facing dental hygiene, as well as dental, education is to identify clinical teaching strategies promoting critical thinking and clinical reasoning. These skills are crucial elements in the practice of dental hygiene. A two-group design (intervention, n=28, and control, n=30) assessed first-year dental hygiene students using pre-and post-Health Science Reasoning Test (HSRT) scores to evaluate the effect of reflective blogging on critical thinking skills. A reflective blog rubric, based on Mezirow's levels of reflection, determined if reflective blogging increased the level of reflection for dental hygiene students. The results suggest within this nonprobability sample that reflective blogging did not produce a significant change in students' HSRT scores (p>0.05). However, analyses of reflective blog rubric scores demonstrated statistically significant improvements (p<0.05) in students' levels of reflection. Furthermore, data analysis revealed a correlation (p<0.05) between HSRT subscale scores and the element of reflection scores for the intervention group. This study addressed needs of the dental and dental hygiene education community by examining the use of blogs, an emerging technology, as a tool for reflecting on clinical experiences and, in turn, for promoting critical thinking.

Clinical validation of the General Ability Index--Estimate (GAI-E): estimating premorbid GAI.

PubMed

Schoenberg, Mike R; Lange, Rael T; Iverson, Grant L; Chelune, Gordon J; Scott, James G; Adams, Russell L

2006-09-01

The clinical utility of the General Ability Index--Estimate (GAI-E; Lange, Schoenberg, Chelune, Scott, & Adams, 2005) for estimating premorbid GAI scores was investigated using the WAIS-III standardization clinical trials sample (The Psychological Corporation, 1997). The GAI-E algorithms combine Vocabulary, Information, Matrix Reasoning, and Picture Completion subtest raw scores with demographic variables to predict GAI. Ten GAI-E algorithms were developed combining demographic variables with single subtest scaled scores and with two subtests. Estimated GAI are presented for participants diagnosed with dementia (n = 50), traumatic brain injury (n = 20), Huntington's disease (n = 15), Korsakoff's disease (n = 12), chronic alcohol abuse (n = 32), temporal lobectomy (n = 17), and schizophrenia (n = 44). In addition, a small sample of participants without dementia and diagnosed with depression (n = 32) was used as a clinical comparison group. The GAI-E algorithms provided estimates of GAI that closely approximated scores expected for a healthy adult population. The greatest differences between estimated GAI and obtained GAI were observed for the single subtest GAI-E algorithms using the Vocabulary, Information, and Matrix Reasoning subtests. Based on these data, recommendations for the use of the GAI-E algorithms are presented.

A pilot study of distributed knowledge management and clinical decision support in the cloud.

PubMed

Dixon, Brian E; Simonaitis, Linas; Goldberg, Howard S; Paterno, Marilyn D; Schaeffer, Molly; Hongsermeier, Tonya; Wright, Adam; Middleton, Blackford

2013-09-01

Implement and perform pilot testing of web-based clinical decision support services using a novel framework for creating and managing clinical knowledge in a distributed fashion using the cloud. The pilot sought to (1) develop and test connectivity to an external clinical decision support (CDS) service, (2) assess the exchange of data to and knowledge from the external CDS service, and (3) capture lessons to guide expansion to more practice sites and users. The Clinical Decision Support Consortium created a repository of shared CDS knowledge for managing hypertension, diabetes, and coronary artery disease in a community cloud hosted by Partners HealthCare. A limited data set for primary care patients at a separate health system was securely transmitted to a CDS rules engine hosted in the cloud. Preventive care reminders triggered by the limited data set were returned for display to clinician end users for review and display. During a pilot study, we (1) monitored connectivity and system performance, (2) studied the exchange of data and decision support reminders between the two health systems, and (3) captured lessons. During the six month pilot study, there were 1339 patient encounters in which information was successfully exchanged. Preventive care reminders were displayed during 57% of patient visits, most often reminding physicians to monitor blood pressure for hypertensive patients (29%) and order eye exams for patients with diabetes (28%). Lessons learned were grouped into five themes: performance, governance, semantic interoperability, ongoing adjustments, and usability. Remote, asynchronous cloud-based decision support performed reasonably well, although issues concerning governance, semantic interoperability, and usability remain key challenges for successful adoption and use of cloud-based CDS that will require collaboration between biomedical informatics and computer science disciplines. Decision support in the cloud is feasible and may be a reasonable path toward achieving better support of clinical decision-making across the widest range of health care providers. Published by Elsevier B.V.

Generalizability of Evidence-Based Assessment Recommendations for Pediatric Bipolar Disorder

PubMed Central

Jenkins, Melissa M.; Youngstrom, Eric A.; Youngstrom, Jennifer Kogos; Feeny, Norah C.; Findling, Robert L.

2013-01-01

Bipolar disorder is frequently clinically diagnosed in youths who do not actually satisfy DSM-IV criteria, yet cases that would satisfy full DSM-IV criteria are often undetected clinically. Evidence-based assessment methods that incorporate Bayesian reasoning have demonstrated improved diagnostic accuracy, and consistency; however, their clinical utility is largely unexplored. The present study examines the effectiveness of promising evidence-based decision-making compared to the clinical gold standard. Participants were 562 youth, ages 5-17 and predominantly African American, drawn from a community mental health clinic. Research diagnoses combined semi-structured interview with youths’ psychiatric, developmental, and family mental health histories. Independent Bayesian estimates relied on published risk estimates from other samples discriminated bipolar diagnoses, Area Under Curve=.75, p<.00005. The Bayes and confidence ratings correlated rs =.30. Agreement about an evidence-based assessment intervention “threshold model” (wait/assess/treat) had K=.24, p<.05. No potential moderators of agreement between the Bayesian estimates and confidence ratings, including type of bipolar illness, were significant. Bayesian risk estimates were highly correlated with logistic regression estimates using optimal sample weights, r=.81, p<.0005. Clinical and Bayesian approaches agree in terms of overall concordance and deciding next clinical action, even when Bayesian predictions are based on published estimates from clinically and demographically different samples. Evidence-based assessment methods may be useful in settings that cannot routinely employ gold standard assessments, and they may help decrease rates of overdiagnosis while promoting earlier identification of true cases. PMID:22004538

An IT Architecture for Systems Medicine.

PubMed

Ganzinger, Matthias; Gietzelt, Matthias; Karmen, Christian; Firnkorn, Daniel; Knaup, Petra

2015-01-01

Systems medicine aims to support treatment of complex diseases like cancer by integrating all available data for the disease. To provide such a decision support in clinical practice, a suitable IT architecture is necessary. We suggest a generic architecture comprised of the following three layers: data representation, decision support, and user interface. For the systems medicine research project "Clinically-applicable, omics-based assessment of survival, side effects, and targets in multiple myeloma" (CLIOMMICS) we developed a concrete instance of the generic architecture. We use i2b2 for representing the harmonized data. Since no deterministic model exists for multiple myeloma we use case-based reasoning for decision support. For clinical practice, visualizations of the results must be intuitive and clear. At the same time, they must communicate the uncertainty immanent in stochastic processes. Thus, we develop a specific user interface for systems medicine based on the web portal software Liferay.

Computerized Assessment of Competence-Related Abilities in Living Liver Donors: The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL)

PubMed Central

Freeman, Jason; Emond, Jean; Gillespie, Brenda W.; Appelbaum, Paul S.; Weinrieb, Robert; Hill-Callahan, Peg; Gordon, Elisa J.; Terrault, Norah; Trotter, James; Ashworth, April; Dew, Mary Amanda; Pruett, Timothy

2014-01-01

Background Despite its importance, determination of competence to consent to organ donation varies widely based on local standards. We piloted a new tool to aid transplant centers in donor assessment. Methods We assessed competence-related abilities among potential living liver donors (LDs) in the 9-center A2ALL study. Prospective LDs viewed an educational video, and were queried to assess Understanding, Appreciation, Reasoning, and ability to express a Final Choice using the MacArthur Competence Assessment Tool for Clinical Research, adapted for computerized administration in LDs (“MacLiver”). Videotaped responses were scored by a clinical neuropsychologist (JF). Results Ninety-three LDs were assessed. Mean (standard deviation; domain maximum) scores were: Understanding: 18.1 (2.6; max=22), Appreciation: 5.1 (1.0; max=6), Reasoning: 3.1 (0.8; max=4), and Final Choice: 3.8 (0.5; max=4). Scores did not differ by demographics, relationship to the recipient, eligibility to donate, or eventual donation (p>0.4). Higher education was associated with greater Understanding (p=0.004) and Reasoning (p=0.03). Conclusion Standardized, computerized education with independent ratings of responses may (1) alert the clinical staff to potential donors who may not be competent to donate, and (2) highlight areas needing further assessment and education, leading to better informed decision-making. PMID:23859354

Clinical reasoning in nursing: teaching strategies and assessment tools.

PubMed

Carvalho, Emília Campos de; Oliveira-Kumakura, Ana Railka de Souza; Morais, Sheila Coelho Ramalho Vasconcelos

2017-01-01

To present the concept and development of teaching strategies and the assessment tools regarding clinical reasoning for accurate practice. This is a theoretical reflection based on scientific studies. Comprehension of the essential concepts of the thought process and its articulation with the different teaching strategies and the assessment tools which has allowed presenting ways to improve the process of diagnostic or therapeutic clinical reasoning. The use of new strategies and assessment tools should be encouraged in order to contribute to the development of skills that lead to safe and effective decision making. Apresentar o conceito de raciocínio clínico, seu desenvolvimento, as estratégias para seu ensino e os instrumentos de avaliação para uma prática acurada. Trata-se de uma reflexão teórica fundamentada em estudos científicos. A compreensão dos conceitos essenciais do processo de pensamento e sua articulação com as diferentes estratégias de ensino e com os instrumentos de avaliação permitiram exemplificar meios de aprimorar o processo de raciocínio clínico diagnóstico ou terapêutico. A utilização de novas estratégias e instrumentos de avaliação deve ser estimulado para contribuir com o desenvolvimento das habilidades que culminam na tomada de decisão segura e eficaz.

Baseline Morbidity in 2,990 Adult African Volunteers Recruited to Characterize Laboratory Reference Intervals for Future HIV Vaccine Clinical Trials

PubMed Central

Stevens, Wendy; Kamali, Anatoli; Karita, Etienne; Anzala, Omu; Sanders, Eduard J.; Jaoko, Walter; Kaleebu, Pontiano; Mulenga, Joseph; Dally, Len; Fast, Pat; Gilmour, Jill; Farah, Bashir; Birungi, Josephine; Hughes, Peter; Manigart, Olivier; Stevens, Gwynn; Yates, Sarah; Thomson, Helen; von Lieven, Andrea; Krebs, Marietta; Price, Matt A.; Stoll-Johnson, Lisa; Ketter, Nzeera

2008-01-01

Background An understanding of the health of potential volunteers in Africa is essential for the safe and efficient conduct of clinical trials, particularly for trials of preventive technologies such as vaccines that enroll healthy individuals. Clinical safety laboratory values used for screening, enrolment and follow-up of African clinical trial volunteers have largely been based on values derived from industrialized countries in Europe and North America. This report describes baseline morbidity during recruitment for a multi-center, African laboratory reference intervals study. Methods Asymptomatic persons, aged 18–60 years, were invited to participate in a cross-sectional study at seven sites (Kigali, Rwanda; Masaka and Entebbe, Uganda; Kangemi, Kenyatta National Hospital and Kilifi, Kenya; and Lusaka, Zambia). Gender equivalency was by design. Individuals who were acutely ill, pregnant, menstruating, or had significant clinical findings were not enrolled. Each volunteer provided blood for hematology, immunology, and biochemistry parameters and urine for urinalysis. Enrolled volunteers were excluded if found to be positive for HIV, syphilis or Hepatitis B and C. Laboratory assays were conducted under Good Clinical Laboratory Practices (GCLP). Results and Conclusions Of the 2990 volunteers who were screened, 2387 (80%) were enrolled, and 2107 (71%) were included in the analysis (52% men, 48% women). Major reasons for screening out volunteers included abnormal findings on physical examination (228/603, 38%), significant medical history (76, 13%) and inability to complete the informed consent process (73, 13%). Once enrolled, principle reasons for exclusion from analysis included detection of Hepatitis B surface antigen (106/280, 38%) and antibodies against Hepatitis C (95, 34%). This is the first large scale, multi-site study conducted to the standards of GCLP to describe African laboratory reference intervals applicable to potential volunteers in clinical trials. Approximately one-third of all potential volunteers screened were not eligible for analysis; the majority were excluded for medical reasons. PMID:18446196

Altruism as a reason for participation in clinical trials was independently associated with adherence.

PubMed

Rosenbaum, Julie R; Wells, Carolyn K; Viscoli, Catherine M; Brass, Lawrence M; Kernan, Walter N; Horwitz, Ralph I

2005-11-01

To determine whether altruism as reason for participation in research is independently associated with adherence to a medical regimen in a clinical trial. Participants were 475 participants in the Women's Estrogen for Stroke Trial. Before randomization to estrogen or placebo, all women were questioned about reason for participation and baseline features that may contribute to adherence. Adherence was defined as completion of at least 80% of expected pill intake during the trial. Women who reported at least one altruistic reason for participation were more likely to be college educated, have a higher level of social support, and a better functional status. They were also more likely to be adherent to their study medication {155 of 212 (73%) vs. 158 of 253 (62.5%), P < .01}. On stratified analysis and multivariable regression, the relationship between altruism as reason for participation and adherence was independent of other sociodemographic, psychosocial, and clinical features (relative risk 1.17, Confidence interval 1.03-1.32). Altruism may explain a small portion of the variation in adherence among research participants. This relationship may have implications for recruitment of participants in clinical research. The possible contribution of altruism to the relationship between adherence and outcomes in clinical trials is worthy of further investigation.

Internal Medicine residents use heuristics to estimate disease probability.

PubMed

Phang, Sen Han; Ravani, Pietro; Schaefer, Jeffrey; Wright, Bruce; McLaughlin, Kevin

2015-01-01

Training in Bayesian reasoning may have limited impact on accuracy of probability estimates. In this study, our goal was to explore whether residents previously exposed to Bayesian reasoning use heuristics rather than Bayesian reasoning to estimate disease probabilities. We predicted that if residents use heuristics then post-test probability estimates would be increased by non-discriminating clinical features or a high anchor for a target condition. We randomized 55 Internal Medicine residents to different versions of four clinical vignettes and asked them to estimate probabilities of target conditions. We manipulated the clinical data for each vignette to be consistent with either 1) using a representative heuristic, by adding non-discriminating prototypical clinical features of the target condition, or 2) using anchoring with adjustment heuristic, by providing a high or low anchor for the target condition. When presented with additional non-discriminating data the odds of diagnosing the target condition were increased (odds ratio (OR) 2.83, 95% confidence interval [1.30, 6.15], p = 0.009). Similarly, the odds of diagnosing the target condition were increased when a high anchor preceded the vignette (OR 2.04, [1.09, 3.81], p = 0.025). Our findings suggest that despite previous exposure to the use of Bayesian reasoning, residents use heuristics, such as the representative heuristic and anchoring with adjustment, to estimate probabilities. Potential reasons for attribute substitution include the relative cognitive ease of heuristics vs. Bayesian reasoning or perhaps residents in their clinical practice use gist traces rather than precise probability estimates when diagnosing.

Dementia diagnoses from clinical and neuropsychological data compared: the Cache County study.

PubMed

Tschanz, J T; Welsh-Bohmer, K A; Skoog, I; West, N; Norton, M C; Wyse, B W; Nickles, R; Breitner, J C

2000-03-28

To validate a neuropsychological algorithm for dementia diagnosis. We developed a neuropsychological algorithm in a sample of 1,023 elderly residents of Cache County, UT. We compared algorithmic and clinical dementia diagnoses both based on DSM-III-R criteria. The algorithm diagnosed dementia when there was impairment in memory and at least one other cognitive domain. We also tested a variant of the algorithm that incorporated functional measures that were based on structured informant reports. Of 1,023 participants, 87% could be classified by the basic algorithm, 94% when functional measures were considered. There was good concordance between basic psychometric and clinical diagnoses (79% agreement, kappa = 0.57). This improved after incorporating functional measures (90% agreement, kappa = 0.76). Neuropsychological algorithms may reasonably classify individuals on dementia status across a range of severity levels and ages and may provide a useful adjunct to clinical diagnoses in population studies.

Exploring the Influence of an E-Learning Sensory Processing-Based Module for Graduate Level Occupational Therapy Students on Clinical Reasoning: A Pilot Study.

PubMed

Gee, Bryan M; Strickland, Jane; Thompson, Kelly; Miller, Lucy Jane

2017-01-01

The purpose of this study was to explore the effectiveness of a series of online, module-based instructional reusable learning objects (RLOs) targeted at entry-level, 1st year, Master of Occupational Therapy students. The content of the RLOs addressed knowledge and implementation of A SECRET, a parental reasoning approach for children with a sensory processing disorder, specifically sensory over responsiveness. Nine RLOs were developed and embedded within a commonly used learning management system. Participants ( n = 8) were evaluated regarding their ability to discriminate between appropriate and inappropriate A SECRET strategies using a selected-response assessment. The participants' overall average score was 68%, a positive finding given the novelty of the instruction, assessment, and the content.

Conditional reasoning in Asperger's syndrome and depersonalization disorder.

PubMed

Lawrence, Emma Jane; Dumigan, Rachael; Schoenberg, Poppy; Mauricio, Sierra; Murphy, Declan G; David, Anthony S

2012-09-01

Conditional reasoning premises can be systematically manipulated to elicit specific response patterns. This is useful for investigating the reasoning style of people who report clinical symptoms. We administered a standardized conditional reasoning task to 16 participants with a diagnosis of Asperger's syndrome (AS), 16 participants with a diagnosis of depersonalization disorder (DPD), and 32 intelligence-quotient-matched controls. Premises were manipulated for a) context, with some being embedded within extra statements, and b) content, neutral or emotional. Both the AS and DPD participants were less likely to incorporate exceptions to the given premises than the controls, indicating difficulties with mental flexibility, although this effect was less marked in the DPD group. It seems the AS participants were also less influenced than the controls by statements that highlight possible alternative consequences. However, this effect was less robust than that observed with statements detailing exceptions, suggesting it may be because of general problems with executive function rather than difficulties in processing contextual information. We did not observe the expected difference between the DPD participants and the controls when reasoning with emotional premises. Overall, these data suggest that the DPD and AS participants have distinct reasoning styles, which may be of use for interventions based on cognitive change.

Diagnosis support system based on clinical guidelines: comparison between case-based fuzzy cognitive maps and Bayesian networks.

PubMed

Douali, Nassim; Csaba, Huszka; De Roo, Jos; Papageorgiou, Elpiniki I; Jaulent, Marie-Christine

2014-01-01

Several studies have described the prevalence and severity of diagnostic errors. Diagnostic errors can arise from cognitive, training, educational and other issues. Examples of cognitive issues include flawed reasoning, incomplete knowledge, faulty information gathering or interpretation, and inappropriate use of decision-making heuristics. We describe a new approach, case-based fuzzy cognitive maps, for medical diagnosis and evaluate it by comparison with Bayesian belief networks. We created a semantic web framework that supports the two reasoning methods. We used database of 174 anonymous patients from several European hospitals: 80 of the patients were female and 94 male with an average age 45±16 (average±stdev). Thirty of the 80 female patients were pregnant. For each patient, signs/symptoms/observables/age/sex were taken into account by the system. We used a statistical approach to compare the two methods. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Analyzing reflective narratives to assess the ethical reasoning of pediatric residents.

PubMed

Moon, Margaret; Taylor, Holly A; McDonald, Erin L; Hughes, Mark T; Beach, Mary Catherine; Carrese, Joseph A

2013-01-01

A limiting factor in ethics education in medical training has been difficulty in assessing competence in ethics. This study was conducted to test the concept that content analysis of pediatric residents' personal reflections about ethics experiences can identify changes in ethical sensitivity and reasoning over time. Analysis of written narratives focused on two of our ethics curriculum's goals: 1) To raise sensitivity to ethical issues in everyday clinical practice and 2) to enhance critical reflection on personal and professional values as they affect patient care. Content analysis of written reflections was guided by a tool developed to identify and assess the level of ethical reasoning in eight domains determined to be important aspects of ethical competence. Based on the assessment of narratives written at two times (12 to 16 months/apart) during their training, residents showed significant progress in two specific domains: use of professional values, and use of personal values. Residents did not show decline in ethical reasoning in any domain. This study demonstrates that content analysis of personal narratives may provide a useful method for assessment of developing ethical sensitivity and reasoning.

Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel.

PubMed

Shmueli, Liora; Davidovitch, Nadav; Pliskin, Joseph S; Balicer, Ran D; Hekselman, Igal; Greenfield, Geva

2017-12-08

Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO. A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one. Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%). Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions.

Use of the script concordance approach to evaluate clinical reasoning in food-ruminant practitioners.

PubMed

Dufour, Simon; Latour, Sylvie; Chicoine, Yvan; Fecteau, Gilles; Forget, Sylvain; Moreau, Jean; Trépanier, André

2012-01-01

A script concordance test (SCT) was developed measuring clinical reasoning of food-ruminant practitioners for whom potential clinical competence difficulties were identified by their provincial professional organization. The SCT was designed to be used as part of a broader evaluation procedure. A scoring key was developed based on answers from a reference panel of 12 experts and using the modified aggregate method commonly used for SCTs. A convenient sample of 29 food-ruminant practitioners was constituted to assess the reliability and precision of the SCT and to determine a fair threshold value for success. Cronbach's α coefficients were computed to evaluate internal reliability. To evaluate SCT precision, a test-retest methodology was used and measures of agreement beyond chance were computed at question and test levels. After optimization, the 36-question SCT yielded acceptable internal reliability (Cronbach's α=0.70). Precision of the SCT at question level was excellent with 33 questions (92%) yielding moderate to almost perfect agreement between administrations. At test level, fair agreement (concordance correlation coefficient=0.32) was observed between administrations. A slight SCT score improvement (M=+2.8 points) on the second administration was in part responsible for some of the disagreement and was potentially a result of an adaptation to the SCT format. Scores distribution was used to determine a fair threshold value for success, while considering the underlying objectives of the examination. The data suggest that the developed SCT can be used as a reliable and precise measurement of clinical reasoning of food-ruminant practitioners.

The role of emotions in moral case deliberation: theory, practice, and methodology.

PubMed

Molewijk, Bert; Kleinlugtenbelt, Dick; Widdershoven, Guy

2011-09-01

In clinical moral decision making, emotions often play an important role. However, many clinical ethicists are ignorant, suspicious or even critical of the role of emotions in making moral decisions and in reflecting on them. This raises practical and theoretical questions about the understanding and use of emotions in clinical ethics support services. This paper presents an Aristotelian view on emotions and describes its application in the practice of moral case deliberation. According to Aristotle, emotions are an original and integral part of (virtue) ethics. Emotions are an inherent part of our moral reasoning and being, and therefore they should be an inherent part of any moral deliberation. Based on Aristotle's view, we examine five specific aspects of emotions: the description of emotions, the attitude towards emotions, the thoughts present in emotions, the reliability of emotions, and the reasonable principle that guides an emotion. We then discuss three ways of dealing with emotions in the process of moral case deliberation. Finally, we present an Aristotelian conversation method, and present practical experiences using this method. © 2011 Blackwell Publishing Ltd.

Reducing cognitive skill decay and diagnostic error: theory-based practices for continuing education in health care.

PubMed

Weaver, Sallie J; Newman-Toker, David E; Rosen, Michael A

2012-01-01

Missed, delayed, or wrong diagnoses can have a severe impact on patients, providers, and the entire health care system. One mechanism implicated in such diagnostic errors is the deterioration of cognitive diagnostic skills that are used rarely or not at all over a prolonged period of time. Existing evidence regarding maintenance of effective cognitive reasoning skills in the clinical education, organizational training, and human factors literatures suggest that continuing education plays a critical role in mitigating and managing diagnostic skill decay. Recent models also underscore the role of system level factors (eg, cognitive decision support tools, just-in-time training opportunities) in supporting clinical reasoning process. The purpose of this manuscript is to offer a multidisciplinary review of cognitive models of clinical decision making skills in order to provide a list of best practices for supporting continuous improvement and maintenance of cognitive diagnostic processes through continuing education. Copyright © 2012 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.

Evidence Based-Practice and Affect: The Impact of Physician Attitudes on Outcomes Associated with Clinical Reasoning and Decision-Making

ERIC Educational Resources Information Center

Dunphy, Bruce; Dunphy, Stacey; Cantwell, Robert; Bourke, Sid; Fleming, Mark

2010-01-01

The relationship between obstetrician attitudes and patient outcomes from intrapartum care was examined. Obstetrician attitudes were assessed utilizing a newly-designed pilot 35-item obstetrician attitude questionnaire (OAQ). Twelve obstetricians completed the OAQ, who provided intra-partum care to 4,149 women. Outcome measures included delivery…

21 CFR 314.610 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2014 CFR

2014-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.610 Approval... establish that the drug product is reasonably likely to produce clinical benefit in humans. In assessing the...

21 CFR 314.610 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2012 CFR

2012-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.610 Approval... establish that the drug product is reasonably likely to produce clinical benefit in humans. In assessing the...

21 CFR 314.610 - Approval based on evidence of effectiveness from studies in animals.

Code of Federal Regulations, 2013 CFR

2013-04-01

... HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS FOR HUMAN USE APPLICATIONS FOR FDA APPROVAL TO MARKET A NEW DRUG Approval of New Drugs When Human Efficacy Studies Are Not Ethical or Feasible § 314.610 Approval... establish that the drug product is reasonably likely to produce clinical benefit in humans. In assessing the...

Microcomputer-Based Genetics Office Database System

PubMed Central

Cutts, James H.; Mitchell, Joyce A.

1985-01-01

A database management system (Genetics Office Automation System, GOAS) has been developed for the Medical Genetics Unit of the University of Missouri. The system, which records patients' visits to the Unit's genetic and prenatal clinics, has been implemented on an IBM PC/XT microcomputer. A description of the system, the reasons for implementation, its databases, and uses are presented.

Adolescent Judgments and Reasoning about the Failure to Include Peers with Social Disabilities

ERIC Educational Resources Information Center

Bottema-Beutel, Kristen; Li, Zhushan

2015-01-01

Adolescents with autism spectrum disorder often do not have access to crucial peer social activities. This study examines how typically developing adolescents evaluate decisions not to include a peer based on disability status, and the justifications they apply to these decisions. A clinical interview methodology was used to elicit judgments and…

Investigating High-School Students' Reasoning Strategies when They Solve Linear Equations

ERIC Educational Resources Information Center

Huntley, Mary Ann; Marcus, Robin; Kahan, Jeremy; Miller, Jane Lincoln

2007-01-01

A cross-curricular structured-probe task-based clinical interview study with 44 pairs of third-year high-school mathematics students, most of whom were high achieving, was conducted to investigate their approaches to a variety of algebra problems. This paper presents results from one problem that involved solving a set of three linear equations of…

Reasons for faculty departures from an academic medical center: a survey and comparison across faculty lines.

PubMed

Girod, Sabine C; Fassiotto, Magali; Menorca, Roseanne; Etzkowitz, Henry; Wren, Sherry M

2017-01-10

Faculty departure can present significant intellectual costs to an institution. The authors sought to identify the reasons for clinical and non-clinical faculty departures at one academic medical center (AMC). In May and June 2010, the authors surveyed 137 faculty members who left a west coast School of Medicine (SOM) between 1999 and 2009. In May and June 2015, the same survey was sent to 40 faculty members who left the SOM between 2010-2014, for a total sample size of 177 former faculty members. The survey probed work history and experience, reasons for departure, and satisfaction at the SOM versus their current workplace. Statistical analyses included Pearson's chi-square test of independence and independent sample t-tests to understand quantitative differences between clinical and non-clinical respondents, as well as coding of qualitative open-ended responses. Eighty-eight faculty members responded (50%), including three who had since returned to the SOM. Overall, professional and advancement opportunities, salary concerns, and personal/family reasons were the three most cited factors for leaving. The average length of time at this SOM was shorter for faculty in clinical roles, who expressed lower workplace satisfaction and were more likely to perceive incongruence and inaccuracy in institutional expectations for their success than those in non-clinical roles. Clinical faculty respondents noted difficulty in balancing competing demands and navigating institutional expectations for advancement as reasons for leaving. AMCs may not be meeting faculty needs, especially those in clinical roles who balance multiple missions as clinicians, researchers, and educators. Institutions should address the challenges these faculty face in order to best recruit, retain, and advance faculty.

Lost to follow-up for appointments in a dedicated dry eye clinic

PubMed Central

Poon, Kip Hoe; Yeo, Sharon; Tong, Louis

2014-01-01

Objective Dry eye is a prevalent condition with significant socioeconomic burden. This study evaluates the extent and reasons for loss to follow-up (LTF) in a dedicated dry eye clinic. LTF refers to patient who discontinued visits for >2 years. Method The proportion of patients LTF and the demographics in a cohort of dry eye patients (2006 to 2010) were determined. A telephone survey was prospectively conducted for patients who were LTF. Results Of 505 patients, 240 (47.5%) were LTF. Associated demographic factors for LTF were male sex, non-Chinese ethnicity, and age group <30 years old (all P<0.05). The reasons for LTF through the telephone survey (response rate 77.9%) were categorized into three broad groups, stabilized dry eye condition (47%), personal/social factors (25%) and perceived insufficiency of healthcare delivery (28%). Only two (1.1%) were considered as management failures. The younger patients (age <50 years) were more likely to become LTF (P<0.001) due to stabilized dry eye disease, compared to older patients who were more likely to be LTF due to personal/social reasons (P=0.02). Poor communication and service factors under healthcare delivery were found to be higher (P=0.002) in those who visited once before they were LTF (8.5%) compared to those who visited multiple times before they were LTF (0.1%). Conclusion LTF was relatively common in hospital-based dry eye management. Female and older patients were less likely to stop consultation. Stabilized dry eye condition, common in younger patients, was the most common reason for LTF. Elderly patients have difficulty attending clinics due to nonmedical problems, which may require a more holistic approach. PMID:25336929