Seven characteristics of medical evidence

This paper outlines seven essential characteristics of medical evidence and describes the implications of these for both the theory of evidence-based medicine and clinical practice. The seven characteristics are: (1) Provisional; (2) Defeasible; (3) Emergent; (4) Incomplete; (5) Constrained; (6) Collective and (7) Asymmetric. It is argued that the epistemological theory that best fits medical evidence is that of fallibilism.     

Teaching Diagnostic Skills: Clinical Vignettes or Chief Complaints?

Two formats of case presentation are traditionally used for teaching problem-solving skills: clinical vignette or chief complaint formats. While the first one is more commonly used, it does not completely reflect the actual problem-solving process during a real encounter, which may hamper the learners to integrate separately acquired data gathering skills into their reasoning process and affect their diagnostic performance in practice. The present study compared diagnostic accuracy when the reasoning stimulus was a case vignette containing all diagnostic information versus the patient's chief complaint only. Forty-two medical students, 53 residents and 60 general internists participated in the study. Diagnostic accuracy was significantly lower for the chief complaint format at the student, resident, and practitioner levels. Analysis of the data gathered in the chief-complaint format revealed that faulty diagnostic decisions resulted from a failure to gather critical data. The results suggest that data gathering techniques, semiology, and medical reasoning should be trained in association and that this effort should be pursued beyond medical school.This revised version was published online in October 2005 with corrections to the Cover Date.     

Exploring Alternative Models of Complex Patient Management with Artificial Neural Networks

This study applied an unsupervised neural network modeling process to test data of the National Board of Medical Examiners (NBME) Computer-based Clinical Scenarios (CCS) to identify new performance categories and validate this process as a scoring technique. The classifications resulting from this neural network modeling were consistent with the NBME model in that highly rated NMBE performances (ratings of 7 or 8)were clustered together on the neural network output grid. Very low performance ratings appeared to share few common features and were accordingly classified at isolated nodes. This clustering was reproducible across three separately trained networks with greater than 80% agreement in two of the three network strained. However, the neural network also contained performance clusters where disparate NBME-based ratings ranged from 1 (worst) to 8 (best). Here,agreement between networks was less than 60%. Through visualization of the search strategies (search path mapping), this neural network clustering was found to be sensitive to quantitative and qualitative test selections such as excessive usage of irrelevant tests reflecting broader behavioral classification in some instances. A disparity between NBME ratings and an independent human rating system was detected by the neural network model since disagreement among raters was also reflected by a lack of neural network performance clustering. Agreement between rating systems, however, was correlated with neural network clustering for 92% of the highly rated performances.This revised version was published online in October 2005 with corrections to the Cover Date.     

临床推理研究进展

近30年来国外对临床推理进行了深入的研究,在方法学和理论上取得了很大的进展。按照时间将研究划为三个阶段:①尝试将临床推理理解为一般技巧-临床推理过程研究;②与知识数量和记忆能力相关的记忆-推理研究;③与不同心理表达相关的研究。从中可以归纳出两个观点:首先,尚不能认为推理具有一般过程的变量特征。其次,专业素质与记忆中多个协调的心理表达方式相关。不同的表达方式可能应用于不同的环境,但对引起策略变化的环境特征却知之甚少。专业能力存在于多种知识表达方式之中,通过传授特定的策略、技巧和知识培养临床推理能力并不现实,医学生通过大量精心设计的病例实践来熟悉和理解概念性知识,积累解决问题的经验才是培养临床推理能力的关键。     

Doing practice differently: solution-focused nursing

BACKGROUND: Critical thinking and reasoning take many forms; however, a problem-orientation remains the favoured approach in health care. PURPOSE: This paper considers the effects of a problem-orientation and argues that a solution-orientation fits nursing's interests more closely and represents an exciting way forward in both education and practice. DISCUSSION: Whilst a problem-focus is criticized by some, it remains largely unchallenged as the guiding light for nursing practice. A major reason is that the problem focused approach has strong cultural roots. It is deeply embedded in our thinking, and has become taken-for-granted and not often recognized or debated. Whilst problem-solving has an important place in helping to diagnose disorder and overcome difficulties, nursing needs to move beyond its borders because the role also concerns problem-free issues such as health and well-being. Creativity, imagination and focusing on strengths not problems are also important cognitive processes. CONCLUSION: A problem-orientated approach in nursing has had a constraining rather than enabling influence. By refocusing on a solution-focused approach, we could show how we are different from medicine, and how we aim to do nursing differently through using skills such as engagement, resilience-building, community development, primary health care and health education.     

Identifying occupational therapists' referral priorities in community health

Occupational therapists in British community mental health teams have been debating how the most effective services can be targeted at the most needy clients. This paper presents the results of a quantitative study that examined 40 British occupational therapists' referral prioritization policies. Results showed half of the participants felt their generic responsibilities, which involved having care co-ordination responsibilities, were too large. Only 25% of participants co-ordinated care for clients whose needs were related to occupational dysfunction. Judgement analysis, that involved regressing the 40 individuals' prioritization decisions onto the 90 respective referral scenarios, was used to statistically model how referral information had been weighted. Group agreement of prioritization was moderate with the reason for referral, history of violence and diagnosis being given the most weighting. Consistency in policy application, as measured by examining prioritization decisions on identical referrals, showed wide variability. Further research is required to identify the optimal and most stable policies within this group.     

Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute,long-term,and community health care environments

In an article on a previous study involving hospitalized older adults (McCarthy, 2003), it was argued that the theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion. Further, the theory illuminates how nurses' perspectives toward health in aging affect the ways they regard and ultimately deal with older people in this particular clinical situation. The purpose of the current study was to challenge and refine the theory by exploring the influence of different care environments on clinical reasoning related to acute confusion. Following a period of participant observation, a purposive sample of 30 nurses, 10 each from a teaching hospital, a long-term facility, and a home care agency, participated in semistructured interviews. Dimensional analysis provided the methodological framework for data collection and interpretation. The results reinforce prior findings that the ability of nurses to recognize acute confusion and to distinguish it from dementia can be attributed to their personal philosophies about aging. Care environment was identified as a factor that influenced clinical reasoning in limited ways under certain conditions and within certain contexts.     

Abnormal moral reasoning in complete and partial callosotomy patients

Recent neuroimaging studies suggest lateralized cerebral mechanisms in the right temporal parietal junction are involved in complex social and moral reasoning, such as ascribing beliefs to others. Based on this evidence, we tested 3 anterior-resected and 3 complete callosotomy patients along with 22 normal subjects on a reasoning task that required verbal moral judgments. All 6 patients based their judgments primarily on the outcome of the actions, disregarding the beliefs of the agents. The similarity in performance between complete and partial callosotomy patients suggests that normal judgments of morality require full interhemispheric integration of information critically supported by the right temporal parietal junction and right frontal processes.     

Script concordance test: Insights from the literature and early stages of its implementation in osteopathy

Osteopathic pre-registration education aims to produce competent autonomous practitioners who are capable of dealing with and mastering the uncertainty of clinical practice. The students' preparedness for clinical practice is typically assessed using high fidelity long case exams, i.e., clinical competence assessments using real patients in a real clinical setting. In this paper, we critically review relevant literature concerning the validity, reliability and underpinning educational theory of the Script Concordance Test (SCT), and describe the development, implementation and initial critical evaluation of this assessment tool in the osteopathy programme at Oxford Brookes University. The SCT is an assessment tool aimed at assessing clinical reasoning in the context of uncertainty, which is being increasingly used as an assessment strategy in the field of medical education. Despite its limitations, we believe that the SCT is a useful addition to assessing clinical reasoning in osteopathy, particularly in situations of clinical uncertainty. It has the potential to effectively assess the students' diagnostic reasoning, evaluation of risk and patient safety, and ethical aspects of osteopathic care. Critically, it provides an important vehicle to assess the students' preparedness for autonomous clinical practice using a standardised format.