Do physicians know when their diagnoses are correct?

OBJECTIVE: This study explores the alignment between physicians' confidence in their diagnoses and the "correctness" of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence. DESIGN: Prospective, counterbalanced experimental design. SETTING: Laboratory study conducted under controlled conditions at three academic medical centers. PARTICIPANTS: Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists. INTERVENTION: We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis. MEASUREMENTS AND MAIN RESULTS: A differential was considered "correct" if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were "mildly" aligned (kappa=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%. CONCLUSIONS: Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support.     

Distributed neural representations of logical arguments in school‐age children

Children's understanding of linear‐order (e.g., Dan is taller than Lisa, Lisa is taller than Jess) and set‐inclusion (i.e., All tulips are flowers, All flowers are plants) relationships is critical for the acquisition of deductive reasoning, that is, the ability to reach logically valid conclusions from given premises. Behavioral and neuroimaging studies in adults suggest processing differences between these relations: While arguments that involve linear‐orders may be preferentially associated with spatial processing, arguments that involve set‐inclusions may be preferentially associated with verbal processing. In this study, we used functional magnetic resonance imaging to investigate whether these processing differences appear during the period of elementary school in development. Consistent with previous studies in adults, we found that arguments that involve linear‐order and set‐inclusion relationships preferentially involve spatial and verbal brain mechanisms (respectively) in school‐age children (9–14 year olds). Because this neural sensitivity was not related to age, it likely emerges before the period of elementary education. However, the period of elementary education might play an important role in shaping the neural processing of logical reasoning, as indicated by developmental changes in frontal and parietal regions that were dependent on the type of relation. Hum Brain Mapp 36:996–1009, 2015. © 2014 Wiley Periodicals, Inc.     

Establishing assessment criteria for clinical reasoning in orthopedic manual physical therapy: a consensus-building study

Objectives:

Clinical reasoning (CR) represents one of the core components of clinical competence in Orthopaedic Manual Physical Therapy (OMPT). While education standards have been developed to guide curricular design, assessment of CR has not yet been standardized. Without theory-informed and rigorously developed measures, the certification of OMPTs lacks credibility and is less defensible. The purpose of this study was to use a theory-informed approach to generate assessment criteria for developing new assessment tools to evaluate CR in OMPT.

Methods:

A list of assessment criteria was generated based on international education standards and multiple theoretical perspectives. A modified Delphi method was used to gain expert consensus on the importance of these assessment criteria for the assessment of CR in OMPT. The OMPTs from 22 countries with experience in assessing CR were invited to participate in three rounds of online questionnaires to rate their level of agreement with these criteria. Responses were tabulated to analyze degree of consensus and internal consistency.

Results:

Representatives from almost half of the OMPT member organizations (MO) participated in three rounds of the Delphi. High levels of agreement were found among respondents regarding the importance and feasibility of most assessment criteria. There was high internal consistency among items within the proposed item subgroupings.

Discussion:

A list of assessment criteria has been established that will serve as a framework for developing new assessment tools for CR assessment in OMPT. These criteria will be important for guiding the design of certification processes in OMPT as well as other episodes of CR assessment throughout OMPT training.     

Diseases,patients and the epistemology of practice: mapping the borders of health,medicine and care

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.     

A qualitative grounded theory study of the conceptions of clinical practice in osteopathy – A continuum from technical rationality to professional artistry

How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK.A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview.Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory–practice relationship and their perceived therapeutic role.The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions.     

开放式电子病历临床知识库的探讨

随着电子病历系统研究与实践应用的深入,传统临床知识库已无法满足于临床工作及电子病历智能化发展的需要.针对“电子病历知识库”相关文章进行了检索、阅读、分析,总结出开放式电子病历临床知识库具有维护方便、更新及时、内容全面、符合临床需求等特点,提出了开放式电子病历临床知识库是电子病历智能化发展的基础,通过开放式网络平台实时补充与更新相关临床知识库,进而在预设结构关系的知识库中进行可持续性维护和共享.开放式电子病历临床知识库是解决临床知识得以收集与完善的可行方式.     

Physiotherapists' clinical reasoning about patients with non-specific low back pain,as described by the International Classification of Functioning,Disability and Health

Purpose.?To explore and describe what physiotherapists experience they need to know about patients with non-specific low back pain (NSLBP) to make decisions about intervention.

Method.?Four focus groups containing a total of 21 physiotherapists were carried out in Sweden. Interviews were transcribed and qualitative content analysis performed. The manifest content was coded and categorised, and a theme emerged. Extracted symptoms and signs were linked to ICF codes.

Result.?Physiotherapists' clinical reasoning represented a broad view on low back pain (LBP) including codes from all ICF components. The participants argued for individualisation of intervention to a specific patient's problems. A theme of case complexity emerged, involving three levels: easy case, characterised by impairment in body function with close relation to specific body structures; complex case, characterised by impairments in body function, particular mental functions, activity limitations and participation restrictions, particular management of activity level and very complex case, characterised by impairments in body function, activity limitations and participation restrictions, and contextual factors, with help-seeking behaviour as a particular feature.

Conclusion.?The physiotherapists' clinical reasoning reflected a broad view on patients with NSLBP, with variations related to case complexity. The use of ICF codes contributed to understanding that the physiotherapists applied a broad perspective on NSLBP as a health condition as well as to knowledge about how physiotherapists' understand patients with NSLBP. Physiotherapists' use of the ICF in clinical practice might facilitate identification and assessment of specific patient's back pain problem as they occur in daily life and therefore be helpful in rehabilitation planning. Findings might also have an educational value.     

Problem solving in clinical nursing practice

Problem solving in clinical nursing practice is the essence of good care delivery. This paper gives an overview of a research study which identified the cognitive problem solving process nurses use while delivering care. The study was conducted in the clinical setting and used a qualitative research methodology of observation, followed by in-depth semi-structured interview. The analysis of the study revealed diagnostic reasoning is the process used by clinicians. Information regarding the differences between novices and experts is offered as topics for discussion throughout the paper, and recommendations for changes to educational processes are made.     

关于医院手术观摩转播系统方案的探讨

本文介绍了建立手术观摩转播系统的必要性，通过模拟视频系统和数字视频系统的优缺点的比较，提出了模拟和数字视频系统相结合的一种方案。