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Payne VL, Sattar U, Wright M, Hill E, Butler JM, Macpherson B, Jeppesen A, Del Fiol G, Madaras-Kelly K. Clinician perspectives on how situational context and augmented intelligence design features impact perceived usefulness of sepsis prediction scores embedded within a simulated electronic health record. J Am Med Inform Assoc 2024:ocae089. [PMID: 38661564 DOI: 10.1093/jamia/ocae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/04/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Obtain clinicians' perspectives on early warning scores (EWS) use within context of clinical cases. MATERIAL AND METHODS We developed cases mimicking sepsis situations. De-identified data, synthesized physician notes, and EWS representing deterioration risk were displayed in a simulated EHR for analysis. Twelve clinicians participated in semi-structured interviews to ascertain perspectives across four domains: (1) Familiarity with and understanding of artificial intelligence (AI), prediction models and risk scores; (2) Clinical reasoning processes; (3) Impression and response to EWS; and (4) Interface design. Transcripts were coded and analyzed using content and thematic analysis. RESULTS Analysis revealed clinicians have experience but limited AI and prediction/risk modeling understanding. Case assessments were primarily based on clinical data. EWS went unmentioned during initial case analysis; although when prompted to comment on it, they discussed it in subsequent cases. Clinicians were unsure how to interpret or apply the EWS, and desired evidence on its derivation and validation. Design recommendations centered around EWS display in multi-patient lists for triage, and EWS trends within the patient record. Themes included a "Trust but Verify" approach to AI and early warning information, dichotomy that EWS is helpful for triage yet has disproportional signal-to-high noise ratio, and action driven by clinical judgment, not the EWS. CONCLUSIONS Clinicians were unsure of how to apply EWS, acted on clinical data, desired score composition and validation information, and felt EWS was most useful when embedded in multi-patient views. Systems providing interactive visualization may facilitate EWS transparency and increase confidence in AI-generated information.
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Affiliation(s)
- Velma L Payne
- Kasiska Division of Health Sciences, College of Health, Idaho State University, Pocatello, ID 83209, United States
| | - Usman Sattar
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Melanie Wright
- Tunnell Government Services, Inc., Bethesda, MD 20817, United States
| | - Elijah Hill
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Pocatello, ID 83209, United States
| | - Jorie M Butler
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Brekk Macpherson
- Virginia Commonwealth University Health System, Richmond, VA 83298, United States
| | - Amanda Jeppesen
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Pocatello, ID 83209, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Karl Madaras-Kelly
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Pocatello, ID 83209, United States
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Flenady T, Connor J, Byrne AL, Massey D, Le Lagadec MD. The impact of mandated use early warning system tools on the development of nurses' higher-order thinking: A systematic review. J Clin Nurs 2024. [PMID: 38661093 DOI: 10.1111/jocn.17178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/17/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
AIM Ascertain the impact of mandated use of early warning systems (EWSs) on the development of registered nurses' higher-order thinking. DESIGN A systematic literature review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Page et al., 2021). DATA SOURCES CINAHL, Medline, Embase, PyscInfo. REVIEW METHODS Eligible articles were quality appraised using the MMAT tool. Data extraction was conducted independently by four reviewers. Three investigators thematically analysed the data. RESULTS Our review found that EWSs can support or suppress the development of nurses' higher-order thinking. EWS supports the development of higher-order thinking in two ways; by confirming nurses' subjective clinical assessment of patients and/or by providing a rationale for the escalation of care. Of note, more experienced nurses expressed their view that junior nurses are inhibited from developing effective higher-order thinking due to reliance on the tool. CONCLUSION EWSs facilitate early identification of clinical deterioration in hospitalised patients. The impact of EWSs on the development of nurses' higher-order thinking is under-explored. We found that EWSs can support and suppress nurses' higher-order thinking. EWS as a supportive factor reinforces the development of nurses' heuristics, the mental shortcuts experienced clinicians call on when interpreting their subjective clinical assessment of patients. Conversely, EWS as a suppressive factor inhibits the development of nurses' higher-order thinking and heuristics, restricting the development of muscle memory regarding similar presentations they may encounter in the future. Clinicians' ability to refine and expand on their catalogue of heuristics is important as it endorses the future provision of safe and effective care for patients who present with similar physiological signs and symptoms. IMPACT This research impacts health services and education providers as EWS and nurses' development of higher-order thinking skills are essential aspects of delivering safe, quality care. NO PATIENT OR PUBLIC CONTRIBUTION This is a systematic review, and therefore, comprises no contribution from patients or the public.
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Affiliation(s)
- Tracy Flenady
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Justine Connor
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Amy-Louise Byrne
- Central Queensland University, Rockhampton, Queensland, Australia
| | - Deb Massey
- Edith Cowen University, Joondalup, Western Australia, Australia
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Kıyak YS, Budakoğlu Iİ, Coşkun Ö. Test-Only Learning via Virtual Patients to Improve Surgical Illness Scripts of Preclinical Medical Students as a Preparation for Clinical Clerkships: An Experimental Study. Surg Innov 2024:15533506241246333. [PMID: 38596895 DOI: 10.1177/15533506241246333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE The aim was to determine whether preclinical medical students can develop their illness scripts to a level comparable to that of clerkship students through test-only learning using repeated formative online testlets. METHODS In this experimental study, participants were 52 preclinical and 53 clinical medical students. The intervention group consisted of preclinical medical students, and the control group consisted of clinical medical students. The intervention group responded to online testlets containing feedback, an innovative formative assessment method called ContExtended Questions, on general surgery for 8 days by spending no more than 30 minutes each day. The control group completed the general surgery clerkship. The performances were assessed using 20 Key-Feature Question items. The intervention group was assessed twice: immediately after the intervention (the immediate test), and again 1 month later (the delayed test). The control group was assessed once, immediately after the clerkship. All performance tests were identical. RESULTS The preclinical students had a significantly higher mean score on the immediate test (83.1 ± 9.6) compared to the clinical students (75.4 ± 8.9), P < .001. The effect size (Cohen's d) was .83. However, the mean score in the delayed test (76.9 ± 13.6) was not significantly different from clinical students' mean score (75.4 ± 8.9), P > .05. CONCLUSIONS Test-only learning as a spaced repetition of online formative testlets is effective in preparing preclinical medical students to the clinical clerkship. Through using this approach in preclinical period, they can prepare themselves for the clinical environment to optimize the benefits derived from clerkships.
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Affiliation(s)
- Yavuz Selim Kıyak
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Işıl İrem Budakoğlu
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Özlem Coşkun
- Department of Medical Education and Informatics, Faculty of Medicine, Gazi University, Ankara, Turkey
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Perrot O, Schirmann A, Vidart A, Guillot-Tantay C, Izard V, Lebret T, Boillot B, Mesnard B, Lebacle C, Madec FX. Chatbots vs andrologists: testing 25 clinical cases. Fr J Urol 2024:102636. [PMID: 38599321 DOI: 10.1016/j.fjurol.2024.102636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE AI-derived language models are booming, and their place in medicine is undefined. The aim of our study is to compare responses to andrology clinical cases, between chatbots and andrologists, to assess the reliability of these technologies. MATERIAL AND METHOD We analyzed the responses of 32 experts, 18 residents and three chatbots (ChatGPT v3.5, v4 and Bard) to 25 andrology clinical cases. Responses were assessed on a Likert scale ranging from 0 to 2 for each question (0-false response or no response; 1-partially correct response, 2- correct response), on the basis of the latest national or, in the absence of such, international recommendations. We compared the averages obtained for all cases by the different groups. RESULTS Experts obtained a higher mean score (m=11/12.4 σ=1.4) than ChatGPT v4 (m=10.7/12.4 σ=2.2, p = 0.6475), ChatGPT v3.5 (m=9.5/12.4 σ=2.1, p = 0.0062) and Bard (m=7.2/12.4 σ=3.3, p < 0.0001). Residents obtained a mean score (m=9.4/12.4 σ=1.7) higher than Bard (m=7.2/12.4 σ=3.3, p = 0.0053) but lower than ChatGPT v3.5 (m=9.5/12.4 σ=2.1, p = 0.8393) and v4 (m=10.7/12.4 σ=2.2, p = 0.0183) and experts (m=11.0/12.4 σ=1.4,p=0.0009). ChatGPT v4 performance (m=10.7 σ=2.2) was better than ChatGPT v3.5 (m=9.5, σ=2.1, p = 0.0476) and Bard performance (m=7.2 σ=3.3, p < 0.0001). CONCLUSION The use of chatbots in medicine could be relevant. More studies are needed to integrate them into clinical practice. LEVEL OF EVIDENCE 4
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Affiliation(s)
| | | | | | | | | | | | | | | | - Cedric Lebacle
- Kremlin-Bicetre Hospital, urology department, Kremlin-Bicetre, France
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Albahari D. Perceived opportunities of clinical reasoning learning in postgraduate psychiatry training: Trainees' and faculty's perspectives. Qatar Med J 2024; 2024:14. [PMID: 38650827 PMCID: PMC11034381 DOI: 10.5339/qmj.2024.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Learning clinical reasoning is less effective in isolation of clinical environments because contextual factors are a significant component in the clinical reasoning process. This study investigated the differences in opinions between novice and expert clinicians on learning clinical reasoning in the workplace. MATERIALS AND METHODS The author used a cross-sectional online survey design to investigate the perceived learning of six clinical reasoning skills in 13 learning opportunities. Questionnaires were emailed to 41 postgraduate psychiatry trainee doctors and 37 faculty members. Data were analyzed descriptively. The Chi-square test was used to compare the responses of the two groups. Statistical significance was set at P < 0.05. RESULTS The combined response rate was 73.07%. The two groups perceived the learning of advanced clinical reasoning skills to be lower than that of basic skills. There were significant differences in the perceived learning of basic clinical reasoning skills in self-study/exam preparations (P = 0.032), general hospital grand rounds (P = 0.049), and clinical rounds (P = 0.024 for consultant-led rounds and P = 0.038 for senior peer-led rounds). There were also significant differences in the perceived learning of advanced clinical reasoning skills among peer-led tutorials (P = 0.04), journal clubs (P = 0.006), morning reports (P = 0.002), and on-call duties (P = 0.031). CONCLUSIONS The trainees showed a significant preference for structured learning environments rather than clinical environments, especially for advanced clinical reasoning skills. Trainees likely struggled with cognitive overload in clinical environments. Local postgraduate psychiatry programs will likely benefit from implementing multiple educational interventions that facilitate teaching and learning clinical reasoning in complex clinical environments.
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Sharma H, McDonald CE, Vaughan B, Bower KJ. Teaching clinical reasoning in gerontological physiotherapy: Experiences and perceptions of clinical supervisors. Physiother Theory Pract 2024:1-11. [PMID: 38566578 DOI: 10.1080/09593985.2024.2334750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Teaching clinical reasoning to physiotherapy students is essential for preparing them to work effectively with patients. OBJECTIVE This qualitative study aimed to explore the experiences and perceptions of clinical supervisors of teaching clinical reasoning in gerontological physiotherapy. METHODS Australian-based clinical supervisors for student placements in gerontological physiotherapy (n = 9) participated in individual semi-structured interviews via videoconferencing. Data were analyzed using Braun and Clark's reflexive thematic analysis. RESULTS Four themes were developed from the data: 1) Preparedness for placement: students and supervisors; 2) Dynamic placement adaptations to meet individual learning needs; 3) Negotiating clinically complex and variable patient needs; and 4) Crafting learning opportunities amidst complexities. Clinical supervisors perceive that teaching clinical reasoning is influenced by student and supervisor preparedness and the complexity of gerontological practice. Supervisors engage in planning prior to placements, adapt tasks, discussions and feedback throughout the placement, and promote multi-disciplinary learning experiences to highlight person-centered and collaborative care. CONCLUSION This research enhances physiotherapy academics,' clinical supervisors' and students' understanding of the factors influencing teaching clinical reasoning to students in gerontological settings. The challenges and strategies identified can improve students' and supervisors' preparedness for placements, assist them to negotiate complexity and create opportunities to strengthen the learning experience.
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Affiliation(s)
- Hannah Sharma
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Brett Vaughan
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Kelly J Bower
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
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Rensfeld Flink A, Thunberg G, Nyman A, Broberg M, Åsberg Johnels J. Augmentative and alternative communication with children with severe/profound intellectual and multiple disabilities: speech language pathologists' clinical practices and reasoning. Disabil Rehabil Assist Technol 2024; 19:962-974. [PMID: 36327995 DOI: 10.1080/17483107.2022.2137252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Augmentative and alternative communication (AAC) is recommended to be included in communication interventions directed at children/youth with severe/profound intellectual and multiple disabilities (S/PIMD). Even so, the evidence base for AAC practices with children with S/PIMD is limited. Also, little is known about how frequently AAC is implemented with this target group, which AAC tools and methods are applied, and the related clinical reasoning of speech-language pathologists (SLPs). This study aimed to explore SLPs' beliefs, clinical reasoning and practices in relation to AAC implementation with children/youth with S/PIMD. MATERIALS AND METHODS In this sequential, mixed-methods study, 90 SLPs working with children with disabilities within habilitation services in Sweden participated in an online survey. The survey answers were statistically analysed. Subsequently, focus group data were collected from seven SLPs and analysed using thematic analysis. RESULTS AND CONCLUSIONS Despite AAC being highly prioritized, SLPs found it challenging and complex to implement with this target group. A wide variety of AAC methods and tools were considered and implemented. Clinical decision-making was a balancing act between competing considerations and was mainly guided by the SLPs' individual, clinical experiences. The resources, engagement and wishes of the social network surrounding the child were considered crucial for clinical decision-making on AAC. Implications for research and practice are discussed.Implications for rehabilitationSpeech-language pathologists (SLPs) seemingly find a wide variety of Augmentative and Alternative Communication (AAC), ranging from unaided methods to assistive technology of various complexity, to be potentially suitable for children/youth with severe/profound intellectual and multiple disabilities (S/PIMD).The motivation and preferences of the social network surrounding the child with S/PIMD seem to influence SLPs' clinical decision-making on AAC to a high degree. Sometimes this may be considered an even more important factor than the abilities of the child.SLPs' clinical decision-making on AAC for children/youth is guided by their individual, clinical experience to a high degree.An increase in family oriented AAC intervention research targeting individuals with S/PIMD could potentially strengthen the association between research and the current, experience-based clinical practice.
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Affiliation(s)
- Anna Rensfeld Flink
- Speech and Language Pathology Unit, Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
- Habilitation & Health, Region Västra Götaland, Vänersborg, Sweden
| | - Gunilla Thunberg
- Speech and Language Pathology Unit, Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
- DART Centre for AAC and AT, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Nyman
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Habilitation & Health, Stockholm, Sweden
| | - Malin Broberg
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Jakob Åsberg Johnels
- Speech and Language Pathology Unit, Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, University of Gothenburg, Gothenburg, Sweden
- Child Neuropsychiatric Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
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Fonseca Â, Ferreira A, Ribeiro L, Moreira S, Duque C. Embracing the future-is artificial intelligence already better? A comparative study of artificial intelligence performance in diagnostic accuracy and decision-making. Eur J Neurol 2024; 31:e16195. [PMID: 38235841 DOI: 10.1111/ene.16195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/18/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE The integration of artificial intelligence (AI) in healthcare has the potential to revolutionize patient care and clinical decision-making. This study aimed to explore the reliability of large language models in neurology by comparing the performance of an AI chatbot with neurologists in diagnostic accuracy and decision-making. METHODS A cross-sectional observational study was conducted. A pool of clinical cases from the American Academy of Neurology's Question of the Day application was used as the basis for the study. The AI chatbot used was ChatGPT, based on GPT-3.5. The results were then compared to neurology peers who also answered the questions-a mean of 1500 neurologists/neurology residents. RESULTS The study included 188 questions across 22 different categories. The AI chatbot demonstrated a mean success rate of 71.3% in providing correct answers, with varying levels of proficiency across different neurology categories. Compared to neurology peers, the AI chatbot performed at a similar level, with a mean success rate of 69.2% amongst peers. Additionally, the AI chatbot achieved a correct diagnosis in 85.0% of cases and it provided an adequate justification for its correct responses in 96.1%. CONCLUSIONS The study highlights the potential of AI, particularly large language models, in assisting with clinical reasoning and decision-making in neurology and emphasizes the importance of AI as a complementary tool to human expertise. Future advancements and refinements are needed to enhance the AI chatbot's performance and broaden its application across various medical specialties.
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Affiliation(s)
- Ângelo Fonseca
- Neurology Department, Hospital Pedro Hispano, ULS-Matosinhos, Matosinhos, Portugal
| | - Axel Ferreira
- Neurology Department, Hospital Pedro Hispano, ULS-Matosinhos, Matosinhos, Portugal
| | - Luís Ribeiro
- Neurology Department, Hospital Pedro Hispano, ULS-Matosinhos, Matosinhos, Portugal
| | - Sandra Moreira
- Neurology Department, Hospital Pedro Hispano, ULS-Matosinhos, Matosinhos, Portugal
| | - Cristina Duque
- Neurology Department, Hospital Pedro Hispano, ULS-Matosinhos, Matosinhos, Portugal
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Lindén M, Braude HD, Herlofson J, Nordgaard J, Kelly RE, Eberhard J. Elephants, bushes, hot porridge… and clinical intuition? Nord J Psychiatry 2024; 78:163-164. [PMID: 38015046 DOI: 10.1080/08039488.2023.2283476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Affiliation(s)
- M Lindén
- Department of Medical History, Faculty of Medicine, Lund University, Lund, Sweden
| | | | | | - J Nordgaard
- Mental Health Center Amager, University Hospital Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - R E Kelly
- Department of Psychiatry, Weill Cornell Medicine, White Plains, NY, USA
- Department of Clinical Sciences Lund/Helsingborg, Lund University, Lund, Sweden
| | - J Eberhard
- Department of Clinical Sciences Lund/Helsingborg, Lund University, Lund, Sweden
- Adult Psychiatric Clinic of Helsingborg, Region Skåne, Helsingborg, Sweden
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Labidi S, Meti N, Barua R, Li M, Riromar J, Jiang DM, Fallah-Rad N, Sridhar SS, Del Rincon SV, Pezo RC, Ferrario C, Cheng S, Sacher AG, Rose AAN. Clinical variables associated with immune checkpoint inhibitor outcomes in patients with metastatic urothelial carcinoma: a multicentre retrospective cohort study. BMJ Open 2024; 14:e081480. [PMID: 38553056 PMCID: PMC10982788 DOI: 10.1136/bmjopen-2023-081480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVES Immune checkpoint inhibitors (ICIs) are indicated for metastatic urothelial cancer (mUC), but predictive and prognostic factors are lacking. We investigated clinical variables associated with ICI outcomes. METHODS We performed a multicentre retrospective cohort study of 135 patients who received ICI for mUC, 2016-2021, at three Canadian centres. Clinical characteristics, body mass index (BMI), metastatic sites, neutrophil-to-lymphocyte ratio (NLR), response and survival were abstracted from chart review. RESULTS We identified 135 patients and 62% had received ICI as a second-line or later treatment for mUC. A BMI ≥25 was significantly correlated to a higher overall response rate (ORR) (45.4% vs 16.3%, p value=0.020). Patients with BMI ≥30 experienced longer median overall survival (OS) of 24.8 vs 14.4 for 25≤BMI<30 and 8.5 months for BMI <25 (p value=0.012). The ORR was lower in the presence of bone metastases (16% vs 41%, p value=0.006) and liver metastases (16% vs 39%, p value=0.013). Metastatic lymph nodes were correlated with higher ORR (40% vs 20%, p value=0.032). The median OS for bone metastases was 7.3 versus 18 months (p value <0.001). Patients with liver metastases had a median OS of 8.6 versus 15 months (p value=0.006). No difference for lymph nodes metastases (13.5 vs 12.7 months, p value=0.175) was found. NLR ≥4 had worse OS (8.2 vs 17.7 months, p value=0.0001). In multivariate analysis, BMI ≥30, bone metastases, NLR ≥4, performance status ≥2 and line of ICI ≥2 were independent factors for OS. CONCLUSIONS Our data identified BMI and bone metastases as novel clinical biomarkers that were independently associated with ICI outcomes in mUC. External and prospective validation are warranted.
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Affiliation(s)
- Soumaya Labidi
- Segal Cancer Centre, Jewish General Hospital, Montreal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
| | - Nicholas Meti
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
- St Mary Hospital, Montreal, Quebec, Canada
| | - Reeta Barua
- Toronto East Health Network Michael Garron Hospital, Toronto, Ontario, Canada
| | - Mengqi Li
- Lady Davis Institute for Medical Research, Montreal, Québec, Canada
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Jamila Riromar
- National Oncology Center, The Royal Hospital, Seeb, Muscat, Oman
| | - Di Maria Jiang
- Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Nazanin Fallah-Rad
- Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Srikala S Sridhar
- Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Sonia V Del Rincon
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
- Lady Davis Institute for Medical Research, Montreal, Québec, Canada
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Rossanna C Pezo
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Cristiano Ferrario
- Segal Cancer Centre, Jewish General Hospital, Montreal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
| | - Susanna Cheng
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Adrian G Sacher
- Medical Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - April A N Rose
- Segal Cancer Centre, Jewish General Hospital, Montreal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
- Lady Davis Institute for Medical Research, Montreal, Québec, Canada
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Nishizawa T, Ishizuka K, Otsuka Y, Nakanishi T, Kawashima A, Miyagami T, Yamashita S. Writing Case Reports Can Improve Seven Components in Clinical Reasoning. Int Med Case Rep J 2024; 17:195-200. [PMID: 38533427 PMCID: PMC10963171 DOI: 10.2147/imcrj.s449310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/17/2024] [Indexed: 03/28/2024] Open
Abstract
Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient's condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.
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Affiliation(s)
- Toshinori Nishizawa
- Department of General Internal Medicine, St Luke's International Hospital, Tokyo, Japan
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Kanagawa, Japan
| | - Yuki Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyuki Nakanishi
- Department of Emergency and General Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Akira Kawashima
- Department of General Internal Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Taiju Miyagami
- Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Shun Yamashita
- Department of General Medicine, Saga University Hospital, Saga, Japan
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
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Butcher RDCGES, Guandalini LS, de Barros ALBL, Damiani BB, Jones DA. Psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Rev Lat Am Enfermagem 2024; 32:e4119. [PMID: 38511736 PMCID: PMC10949848 DOI: 10.1590/1518-8345.6755.4119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/17/2023] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE to test the factorial structure, reliability and convergent validity of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. METHOD this was a psychometric evaluation of the Functional Health Pattern Assessment Screening Tool - Modified Brazilian Version. Seven hundred and seventeen participants answered the data collection instrument consisting of two parts. Part I included a structured questionnaire to collect sociodemographic data and the participants' perceptions and satisfaction with their current health status. Part II consisted of the tool being tested. The internal structure was assessed using Confirmatory Factor Analysis. Convergent validity was evaluated by the correlation of the tool scores with the rates corresponding to self-perception and satisfaction with current health status. Reliability was assessed using Cronbach's alpha. RESULTS the Confirmatory Factor Analysis confirmed a three-factor solution. The factor loadings were significant and varied from 0.16 to 0.75; the fit indices suggested moderate fit of the model. Internal consistency for all three components varied between 0.779 and 0.919. CONCLUSION the findings suggest that the tool is valid and reliable to be used in the Brazilian population, although caution is recommended when interpreting the results due to the moderate fit of the model. BACKGROUND (1) The FHPAST-BR is a structured, valid and reliable Nursing-driven assessment tool. BACKGROUND (2) The tool provides a way of organizing clinical data and easing decision-making. BACKGROUND (3) The FHPAST-BR can be used in clinical practice and research.
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Affiliation(s)
| | | | | | | | - Dorothy Anne Jones
- Boston College, William F Connell School of Nursing, Chesnut Hill, MA, United States of America
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Flores-Cohaila JA, Vizcarra-Jiménez SF, Bermúdez-Peláez MF, Vascones-Román FF, Rivarola-Hidalgo M, Taype-Rondan A. Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials. Diagnosis (Berl) 2024; 0:dx-2023-0149. [PMID: 38446132 DOI: 10.1515/dx-2023-0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Clinical reasoning is crucial in medical practice, yet its teaching faces challenges due to varied clinical experiences, limited time, and absence from competency frameworks. Despite efforts, effective teaching methodologies remain elusive. Strategies like the One Minute Preceptor (OMP) and SNAPPS are proposed as solutions, particularly in workplace settings. SNAPPS, introduced in 2003, offers a structured approach but lacks comprehensive evidence of its effectiveness. Methodological shortcomings hinder discerning its specific effects. Therefore, a systematic review is proposed to evaluate SNAPPS' impact on clinical reasoning teaching. CONTENT We searched PubMed, EMBASE, and CINAHL for randomized controlled trials (RCTs) comparing SNAPPS against other methods. Data selection and extraction were performed in duplicate. Bias and certainty of evidence were evaluated using Cochrane RoB-2 and GRADE approach. SUMMARY We identified five RCTs performed on medical students and residents. Two compared SNAPPS with an active control such as One Minute Preceptor or training with feedback. None reported the effects of SNAPPS in workplace settings (Kirkpatrick Level 3) or patients (Kirkpatrick Level 4). Low to moderate certainty of evidence suggests that SNAPPS increases the total presentation length by increasing discussion length. Low to moderate certainty of evidence may increase the number of differential diagnoses and the expression of uncertainties. Low certainty of evidence suggests that SNAPPS may increase the odds of trainees initiating a management plan and seeking clarification. OUTLOOK Evidence from this systematic review suggests that SNAPPS has some advantages in terms of clinical reasoning, self-directed learning outcomes, and cost-effectiveness. Furthermore, it appears more beneficial when used by residents than medical students. However, future research should explore outcomes outside SNAPPS-related outcomes, such as workplace or patient-related outcomes.
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Affiliation(s)
| | - Sonia F Vizcarra-Jiménez
- Escuela de Medicina Humana, Facultad de Ciencias de la Salud, 120782 Universidad Privada de Tacna , Tacna, Peru
| | | | | | - Marco Rivarola-Hidalgo
- Centro de Estudios e Investigación en Educación Médica y Bioética, 120782 Universidad Privada de Tacna , Tacna, Peru
| | - Alvaro Taype-Rondan
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, 33225 Universidad San Ignacio de Loyola , Lima, Peru
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Fulbrook P, Lovegrove J, Ven S, Miles SJ. Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study. J Adv Nurs 2024. [PMID: 38450740 DOI: 10.1111/jan.16142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/12/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
AIM To assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement. DESIGN Interrater agreement study. METHODS Data were collected from November 2019 to December 2022. Paired nurse-assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence-adjusted and bias-adjusted kappa. RESULTS Ninety-four nurse assessors participated. Absolute agreement of not-at-risk versus at-risk-any-level was substantial, but absolute agreement of risk-level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower-risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher-risk patients. CONCLUSION There were clear differences in pressure injury risk-level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation. IMPACT The results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool. REPORTING METHOD This study adhered to the GRRAS reporting guideline. PATIENT/PUBLIC CONTRIBUTION No patient or public involvement in this study. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Educators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.
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Affiliation(s)
- Paul Fulbrook
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
- School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Josephine Lovegrove
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing, Midwifery & Social Work, Faculty of Health and Behavioural Sciences, The University of Queensland, Herston, Queensland, Australia
| | - Saroeun Ven
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Sandra J Miles
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
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15
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Markowski AM, Watkins MK, Maitland ME, Manske RC, Podoll KR, Hayward LM. Exploring the integration of diagnostic musculoskeletal ultrasound imaging into clinical practice by physical therapists. Physiother Theory Pract 2024; 40:544-555. [PMID: 36259351 DOI: 10.1080/09593985.2022.2135979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Musculoskeletal ultrasound (MSK-US) use for diagnostic purposes is expanding in physical therapy practice. Identifying and describing physical therapy-specific approaches to incorporating MSK-US into the evaluation process is needed. Musculoskeletal ultrasound extends the physical exam to allow clinicians to visualize anatomy and pathophysiology both statically and dynamically. Purpose: To document 1) weekly use of diagnostic MSK-US; and 2) clinical reasoning approach used in challenging patient cases by physical therapists (PTs) registered by Inteleos in musculoskeletal sonography (RMSK-certified). METHODS Longitudinal, observational, cohort study using mixed methods for data collection and analysis. All 23 currently RMSK-certified PTs using MSK-US in clinical practice across the United States were contacted, and 16 participated. Data were collected using an online survey created with the Research Electronic Data Capture System. Participants documented MSK-US clinical use and significant cases using weekly, reflective, online journals for three months. Demographic data were summarized using descriptive statistics. Case data were analyzed thematically. RESULTS Participating RMSK-certified PTs performed 1110 MSK-US examinations over 110 weeks. Clinicians averaged 7 (range 1-25) MSK-US examinations weekly, representing 28% of an average caseload. Examinations contributed significant anatomical/ pathological information 100% of the time. The most common joints scanned were the knee (n = 281), shoulder (n = 254), and wrist (n = 228). Case data revealed three themes: 1) augmenting the clinical evaluation to extend or narrow a diagnosis; 2) outcomes guiding action; and 3) lessons learned from clinical findings. CONCLUSION RMSK-certified PTs regularly used MSK-US to validate and refine their clinical diagnoses and treatment. Ultrasound imaging directly influenced patient care by informing the diagnostic process, guiding treatment, and appropriately identifying referrals.
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Affiliation(s)
- Alycia M Markowski
- Department of Physical Therapy, Movement, and Rehabilitation Science, Northeastern University, 360 Huntington Avenue, Boston, USA
| | - Maureen K Watkins
- Department of Physical Therapy, Movement, and Rehabilitation Science, Northeastern University, 360 Huntington Avenue, Boston, USA
| | - Murray E Maitland
- Department of Rehabilitation Medicine, Division of Physical Therapy, University of Washington, 1959 N.E. Pacific St., Seattle, USA
| | - Robert C Manske
- Doctor of Physical Therapy Program, Wichita State University, 1845 Fairmount Street, Wichita, USA
| | | | - Lorna M Hayward
- Department of Physical Therapy, Movement, and Rehabilitation Science, Northeastern University, 360 Huntington Avenue, Boston, USA
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Kale MS, Morgan O, Wisnivesky J, Schnur J, Diefenbach MA. Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study. Ann Fam Med 2024; 22:103-112. [PMID: 38527820 DOI: 10.1370/afm.3080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 03/27/2024] Open
Abstract
PURPOSE Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients. METHODS We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population. RESULTS We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice. CONCLUSIONS Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.
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Affiliation(s)
- Minal S Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Orly Morgan
- Division of Medical Education, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Wisnivesky
- Division of Medical Education, University of Miami Miller School of Medicine, Miami, Florida
| | - Julie Schnur
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael A Diefenbach
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York
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Argueza BR, Young ES, Deering L, Franco M, Nightingale J, Irving P, Edwell A, McBride D, Marbin J. Integrating Discussions on Racism and Health Equity into Clinical Reasoning Conference. Acad Pediatr 2024; 24:184-189. [PMID: 37567442 DOI: 10.1016/j.acap.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Intentionally discussing racism and health equity in clinical reasoning conference may provide an opportunity to reinforce antiracist praxis. We aimed to understand 1) whether these discussions provide a meaningful opportunity to practice applying an antiracist lens in patient care, 2) the feasibility of implementing these discussions in a clinical reasoning format, and 3) the acceptability to Black, Indigenous, and People of Color (BIPOC) and white residents. METHODS In 2021, 4 clinical reasoning conference pilot sessions were implemented in a pediatrics residency program. Trained faculty facilitated discussions on mitigating inequity in clinical cases. Residents who attended at least 1 session were invited to participate in focus groups, which were analyzed using grounded theory. RESULTS Thirty residents attended each pilot session out of the 30 to 35 who had the opportunity to attend. The focus groups included 6 BIPOC and 6 white residents. The discussions offered a meaningful opportunity to practice recognizing and naming racism. Having faculty facilitators made the discussions more feasible. Both groups experienced benefits and wanted the discussions to continue, but BIPOC residents want more engagement from their white peers. CONCLUSIONS Discussing racism and health equity in clinical reasoning conference was a meaningful, feasible, and acceptable opportunity for antiracist praxis.
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Affiliation(s)
- Bianca R Argueza
- Department of Pediatrics (BR Argueza, L Deering, M Fran co, A Edwell, and D McBride), University of California, San Francisco.
| | - Elisabeth S Young
- Department of Pediatrics (ES Young), Ann & Robert H. Lurie Children's Hospital of Chicago, Ill.
| | - Laura Deering
- Department of Pediatrics (BR Argueza, L Deering, M Fran co, A Edwell, and D McBride), University of California, San Francisco.
| | - Mauricio Franco
- Department of Pediatrics (BR Argueza, L Deering, M Fran co, A Edwell, and D McBride), University of California, San Francisco.
| | | | - Paul Irving
- Department of Orthopaedic Surgery (P Irving), University of California, San Francisco.
| | - April Edwell
- Department of Pediatrics (BR Argueza, L Deering, M Fran co, A Edwell, and D McBride), University of California, San Francisco.
| | - Dannielle McBride
- Department of Pediatrics (BR Argueza, L Deering, M Fran co, A Edwell, and D McBride), University of California, San Francisco.
| | - Jyothi Marbin
- University of California, Berkeley - University of California, San Francisco Joint Medical Program (J Marbin).
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Samaraweera BP, Pillay M, Muttiah N, Moodley L. Exploring clinical reasoning in child language assessment through decoloniality. Int J Speech Lang Pathol 2024:1-16. [PMID: 38425227 DOI: 10.1080/17549507.2023.2296864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE Clinical reasoning has been taught, practised, and researched under Western epistemologies, which have been fallible in addressing the complexity of clinical reasoning within Indigenous cultures and societies. We explored how speech-language pathologists in Sri Lanka negotiate and value Indigenous and Western perspectives in clinical reasoning within a decolonial framework. METHOD This study used participatory research methodology within the decolonised qualitative research paradigm to produce data collaboratively with eight Sri Lankan speech-language pathologists. Oral history narratives and object-based textual reflections generated the necessary data for the study. Systematic visual-textual analysis and reflexive thematic analysis were carried out iteratively, and the data analysis and interpretation were undertaken collaboratively with the participants. RESULT We generated four key themes about professional education, individuality in practice, holistic thinking, and balancing interests and priorities. The results demonstrate that social, political, and economic forces impact practitioners' clinical reasoning. CONCLUSION Practising science in its original form within Indigenous contexts is challenging. Colonial roots and imperialism impact the delivery of appropriate services in socially and politically marginalised communities. Practitioners' self-awareness about authentic identities and practical wisdom can develop culturally relevant knowledge for equitable practice.
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Affiliation(s)
- Buddhima P Samaraweera
- Discipline of Speech-Language Therapy, University of KwaZulu-Natal, Durban, South Africa
| | - Mershen Pillay
- Discipline of Speech-Language Therapy, University of KwaZulu-Natal, Durban, South Africa
- Speech-Language Therapy, Massey University, New Zealand
| | - Nimisha Muttiah
- Department of Disability Studies, Faculty of Medicine, University of Kelaniya, Sri Lanka
- Communication Disorders and Sciences, State University of New York, Cortland, NY, USA
| | - Legini Moodley
- Discipline of Speech-Language Therapy, University of KwaZulu-Natal, Durban, South Africa
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Isoda S, Shimizu T, Suzuki T. FRAMED: a framework facilitating insight problem solving. Diagnosis (Berl) 2024; 0:dx-2023-0152. [PMID: 38386688 DOI: 10.1515/dx-2023-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/19/2024] [Indexed: 02/24/2024]
Abstract
Insight has been studied as an element of problem solving in the field of cognitive psychology and may play an important role in clinical reasoning. We propose a new strategy based on theories that promote insight that may help generate further diagnostic hypotheses by reviewing the interpretation of a case and an individual's list of differential diagnoses from multiple perspectives: formation (F), re-encoding (R), analogy (A), modification (M), elaboration (E), and deliberation (D) (FRAMED). The FRAMED strategy may help clinicians overcome misinterpretations and cognitive bias by systematically reflecting on previous clinical reasoning processes from multiple perspectives.
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Affiliation(s)
- Sho Isoda
- Department of General Medicine, 38588 Osaka Medical and Pharmaceutical University Hospital , Takatsuki, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, 365086 Dokkyo Medical University Hospital , Shimotsuga-gun, Japan
| | - Tomio Suzuki
- Department of General Medicine, 38588 Osaka Medical and Pharmaceutical University Hospital , Takatsuki, Japan
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Rezigh A, Rezigh A, Sherman S. Lessons in clinical reasoning - pitfalls, myths, and pearls: a woman brought to a halt. Diagnosis (Berl) 2024; 0:dx-2023-0162. [PMID: 38329454 DOI: 10.1515/dx-2023-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Limitations in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with a diagnosis, as well as how discordance of data can help advance the reasoning process, may reduce such errors. CASE PRESENTATION A 60-year-old woman with Hashimoto thyroiditis, diabetes, and generalized anxiety disorder presented with diffuse arthralgias and myalgias. She had been evaluated by physicians of various specialties and undergone multiple modalities of imaging, as well as a electromyography/nerve conduction study (EMG/NCS), leading to diagnoses of fibromyalgia, osteoarthritis, and lumbosacral plexopathy. Despite treatment for these conditions, she experienced persistent functional decline. The only definitive alleviation of her symptoms identified was in the few days following intra-articular steroid injections for osteoarthritis. On presentation to our institution, she appeared fit with a normal BMI. She was a long-time athlete and had been training consistently until her symptoms began. Prediabetes had been diagnosed the year prior and her A1c progressed despite lifestyle modifications and 10 pounds of intentional weight loss. She reported fatigue, intermittent nausea without emesis, and reduced appetite. Examination revealed intact strength and range of motion in both the shoulders and hips, though testing elicited pain. She had symmetric hyperreflexia as well as a slowed, rigid gait. Autoantibody testing revealed strongly positive serum GAD-65 antibodies which were confirmed in the CSF. A diagnosis of stiff-person syndrome was made. She had an incomplete response to first-line therapy with high-dose benzodiazepines. IVIg was initiated with excellent response and symptom resolution. CONCLUSIONS Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid misdiagnosis and halt diagnostic inertia. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. The case discussant demonstrates the power of iterative reasoning, case progression without commitment to a single diagnosis, and the dangers of both explicit and implicit bias. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to overcoming diagnostic inertia.
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Affiliation(s)
- Austin Rezigh
- Department of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Alec Rezigh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sherman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Chockalingam L, Keniston A, McBeth L, Mutter M. A patient follow-up intervention to improve medical decision making at an internal medicine residency program. Diagnosis (Berl) 2024; 0:dx-2023-0135. [PMID: 38310520 DOI: 10.1515/dx-2023-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/11/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVES Practice-based learning and improvement (PBLI) is an ACGME core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH). METHODS Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices. RESULTS 40 out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies. CONCLUSIONS Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.
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Affiliation(s)
- Leela Chockalingam
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Angela Keniston
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lauren McBeth
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marina Mutter
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Milani A, Saiani L, Misurelli E, Lacapra S, Pravettoni G, Magon G, Mazzocco K. The relevance of the contribution of psychoneuroendocrinoimmunology and psychology of reasoning and decision making to nursing science: A discursive paper. J Adv Nurs 2024. [PMID: 38318634 DOI: 10.1111/jan.16087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 11/20/2023] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
AIM Patients' death or adverse events appear to be associated with poor healthcare decision-making. This might be due to an inability to have an adequate representation of the problem or of the connections among problem-related elements. Changing how a problem is formulated can reduce biases in clinical reasoning. The purpose of this article is to explore the possible contributions of psychoneuroendocrinoimmunology (PNEI) and psychology of reasoning and decision-making (PRDM) to support a new nursing theoretical frame. DESIGN Discursive paper. METHOD This article discusses the main assumptions about nursing and nurses' ability to face patient's problems, suggesting a new approach that integrates knowledge from PNEI and PRDM. While PNEI explains the complexity of systems, highlighting the importance of systems connections in affecting health, PRDM underlines the importance of the informative context in creating a mental representation of the problem. Furthermore, PRDM suggests the need to pay attention to information that is not immediately explicit and its connections. CONCLUSION Nursing recognizes the patient-nurse relationship as the axiom that governs care. The integration of PNEI and PRDM in nursing theoretics allows the expansion of the axiom by providing essential elements to read a new type of relationship: the relationship among information. PNEI explains the relationships between biological systems and the psyche and between the whole individual and the environment; PRDM provides tools for the nurse's analytical thinking system to correctly process information and its connections. IMPACT ON NURSING PRACTICE A theoretical renewal is mandatory to improve nursing reasoning and nursing priority identification. Integrating PNEI and PRDM into nursing theoretics will modify the way professionals approach patients, reducing cognitive biases and medical errors. NO PATIENT OR PUBLIC CONTRIBUTION There was no patient or public involvement in the design or writing of this discursive article.
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Affiliation(s)
- Alessandra Milani
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
- PhD Student, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Eliana Misurelli
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Silvana Lacapra
- Nursing Education, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giorgio Magon
- Nursing Manager, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ketti Mazzocco
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Kotwal S, Singh A, Tackett S, Bery AK, Omron R, Gold D, Newman-Toker DE, Wright SM. Assessing clinical reasoning skills following a virtual patient dizziness curriculum. Diagnosis (Berl) 2024; 11:73-81. [PMID: 38079609 DOI: 10.1515/dx-2023-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/09/2023] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE). METHODS All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated. RESULTS Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04). CONCLUSIONS The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amteshwar Singh
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Tackett
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anand K Bery
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Gold
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M Wright
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bergl PA, Shukla N, Shah J, Khan M, Patel JJ, Nanchal RS. Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study. Diagnosis (Berl) 2024; 11:31-39. [PMID: 38018397 DOI: 10.1515/dx-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 11/02/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES Diagnostic errors are a source of morbidity and mortality in intensive care unit (ICU) patients. However, contextual factors influencing clinicians' diagnostic performance have not been studied in authentic ICU settings. We sought to determine the accuracy of ICU clinicians' diagnostic impressions and to characterize how various contextual factors, including self-reported stress levels and perceptions about the patient's prognosis and complexity, impact diagnostic accuracy. We also explored diagnostic calibration, i.e. the balance of accuracy and confidence, among ICU clinicians. METHODS We conducted an observational cohort study in an academic medical ICU. Between June and August 2019, we interviewed ICU clinicians during routine care about their patients' diagnoses, their confidence, and other contextual factors. Subsequently, using adjudicated final diagnoses as the reference standard, two investigators independently rated clinicians' diagnostic accuracy and on each patient on a given day ("patient-day") using 5-point Likert scales. We conducted analyses using both restrictive and conservative definitions of clinicians' accuracy based on the two reviewers' ratings of accuracy. RESULTS We reviewed clinicians' responses for 464 unique patient-days, which included 255 total patients. Attending physicians had the greatest diagnostic accuracy (77-90 %, rated as three or higher on 5-point Likert scale) followed by the team's primary fellow (73-88 %). Attending physician and fellows were also least affected by contextual factors. Diagnostic calibration was greatest among ICU fellows. CONCLUSIONS Additional studies are needed to better understand how contextual factors influence different clinicians' diagnostic reasoning in the ICU.
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Affiliation(s)
- Paul A Bergl
- Department of Critical Care, Gundersen Health System, La Crosse, WI, USA
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Neehal Shukla
- Cleveland Clinic Foundation, Internal Medicine Residency Program, Cleveland, OH, USA
| | - Jatan Shah
- University of Pittsburgh Medical Centre Chautauqua, Jamestown, NY, USA
| | - Marium Khan
- Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rahul S Nanchal
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Kobayashi T, Ono Y. Medical history-taking by highlighting the time course: PODCAST approach. Diagnosis (Berl) 2024; 11:109-111. [PMID: 37677070 DOI: 10.1515/dx-2023-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Takahiro Kobayashi
- Department of General Medicine, National Defense Medical College, Saitama, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Saitama, Japan
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26
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Mullikin DR, Flanagan RP, Merkebu J, Durning SJ, Soh M. Physiologic measurements of cognitive load in clinical reasoning. Diagnosis (Berl) 2024; 0:dx-2023-0143. [PMID: 38282337 DOI: 10.1515/dx-2023-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/08/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as Heart Rate Variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress. METHODS Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level. RESULTS Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]). CONCLUSIONS Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.
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Affiliation(s)
- Dolores R Mullikin
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, USA
| | - Ryan P Flanagan
- Department of Pediatric Cardiology, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Jerusalem Merkebu
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Steven J Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Michael Soh
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
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Kotwal S, Howell M, Zwaan L, Wright SM. Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes. J Gen Intern Med 2024:10.1007/s11606-024-08625-w. [PMID: 38277023 DOI: 10.1007/s11606-024-08625-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/09/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care. OBJECTIVE To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes. DESIGN A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022. PARTICIPANTS 12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience. APPROACH A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset. RESULTS Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care. CONCLUSIONS The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Mason Howell
- Department of Biosciences, Rice University, Houston, TX, USA
| | - Laura Zwaan
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - Scott M Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Gunasekaran S, Murray J, Doeltgen S. Clinical reasoning during dysphagia assessment and management in acute care: A longitudinal qualitative study. Int J Lang Commun Disord 2024. [PMID: 38251794 DOI: 10.1111/1460-6984.13005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Competent clinical reasoning forms the foundation for effective and efficient clinical swallowing examination (CSE) and consequent dysphagia management decisions. While the nature of initial CSEs has been evaluated, it remains unclear how new information gathered by speech-language therapists (SLTs) throughout a patient's acute-care journey is integrated into their initial clinical reasoning and management processes and used to review and revise initial management recommendations. AIMS To understand how SLTs' clinical reasoning and decision-making regarding dysphagia assessment and management evolve as patients transition through acute hospital care from referral to discharge. METHODS & PROCEDURES A longitudinal, qualitative approach was employed to gather information from two SLTs who managed six patients at a metropolitan acute-care hospital. A retrospective 'think-aloud' protocol was utilized to prompt SLTs regarding their clinical reasoning and decision-making processes during initial and subsequent CSEs and patient interactions. Three types of concept maps were created based on these interviews: a descriptive concept map, a reasoning map and a hypothesis map. All concept maps were evaluated regarding their overall structure, facts gathered, types of reasoning engaged in (inductive versus deductive), types of hypotheses generated, and the diagnosis and management recommendations made following initial CSE and during subsequent dysphagia management. OUTCOMES & RESULTS Initial CSEs involved a rich process of fact-gathering, that was predominantly led by inductive reasoning (hypothesis generation) and some application of deductive reasoning (hypothesis testing), with the primary aims of determining the presence of dysphagia and identifying the safest diet and fluid recommendations. During follow-up assessments, SLTs engaged in increasingly more deductive testing of initial hypotheses, including fact-gathering aimed at determining the tolerance of current diet and fluid recommendations or the suitability for diet and/or fluid upgrade and less inductive reasoning. Consistent with this aim, SLTs' hypotheses were focused primarily on airway protection and medical status during the follow-up phase. Overall, both initial and follow-up swallowing assessments were targeted primarily at identifying suitable management recommendations, and less so on identifying and formulating diagnoses. None of the patients presented with adverse respiratory and/or swallowing outcomes during admission and following discharge from speech pathology. CONCLUSIONS & IMPLICATIONS Swallowing assessment and management across the acute-care journey was observed as a high-quality, patient-centred process characterized by iterative cycles of inductive and deductive reasoning. This approach appears to maximize efficiency without compromising the quality of care. The outcomes of this research encourage further investigation and translation to tertiary and post-professional education contexts as a clear understanding of the processes involved in reaching diagnoses and management recommendations can inform career-long refinement of clinical skills. WHAT THIS PAPER ADDS What is already known on the subject SLTs' clinical reasoning processes during initial CSE employ iterative cycles of inductive and deductive reasoning, reflecting a patient-centred assessment process. To date it is unknown how SLTs engage in clinical reasoning during follow-up assessments of swallowing function, how they assess the appropriateness of initial management recommendations and how this relates to patient outcomes. What this paper adds to the existing knowledge Our longitudinal evaluation of clinical reasoning and decision-making patterns related to swallowing management in acute care demonstrated that SLTs tailored their processes to each patient's presentation. There was an emphasis on monitoring the suitability of the initial management recommendations and the potential for upgrade of diet or compensatory swallowing strategies. The iterative cycles of inductive and deductive reasoning reflect efficient decision-making processes that maintain high-quality clinical care within the acute environment. What are the potential or actual clinical implications of this work? Employing efficient and high-quality clinical reasoning is a hallmark of good dysphagia practice in maximizing positive patient outcomes. Developing approaches to understanding and making explicit clinical reasoning processes of experienced clinicians may assist SLTs of all developmental stages to provide high standards of care.
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Affiliation(s)
- Sulekha Gunasekaran
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Joanne Murray
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Swallowing Neurorehabilitation Research Laboratory, Caring Future Institute, Flinders University, Adelaide, SA, Australia
| | - Sebastian Doeltgen
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Swallowing Neurorehabilitation Research Laboratory, Caring Future Institute, Flinders University, Adelaide, SA, Australia
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Naylor K, Hislop J, Torres K, Mani ZA, Goniewicz K. The Impact of Script Concordance Testing on Clinical Decision-Making in Paramedic Education. Healthcare (Basel) 2024; 12:282. [PMID: 38275562 PMCID: PMC10815909 DOI: 10.3390/healthcare12020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
This study investigates the effectiveness of the Script Concordance Test (SCT) in enhancing clinical reasoning skills within paramedic education. Focusing on the Medical University of Lublin, we evaluated the SCT's application across two cohorts of paramedic students, aiming to understand its potential to improve decision-making skills in emergency scenarios. Our approach, informed by Van der Vleuten's assessment framework, revealed that while the SCT's correlation with traditional methods like multiple-choice questions (MCQs) was limited, its formative nature significantly contributed to improved performance in summative assessments. These findings suggest that the SCT can be an effective tool in paramedic training, particularly in strengthening cognitive abilities critical for emergency responses. The study underscores the importance of incorporating innovative assessment tools like SCTs in paramedic curricula, not only to enhance clinical reasoning but also to prepare students for effective emergency responses. Our research contributes to the ongoing efforts in refining paramedic education and highlights the need for versatile assessment strategies in preparing future healthcare professionals for diverse clinical challenges.
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Affiliation(s)
- Katarzyna Naylor
- Independent Unit of Emergency Medical Services and Specialist Emergency, Medical University of Lublin, Chodzki 7, 20-059 Lublin, Poland
| | - Jane Hislop
- Clinical Education, Edinburgh Medical School, The University of Edinburgh, Edinburgh EH16 4SB, UK;
| | - Kamil Torres
- Department of Didactics and Medical Simulation, Faculty of Medical Sciences, Medical University of Lublin Poland, Chodźki 7, 20-093 Lublin, Poland;
| | - Zakaria A. Mani
- Nursing College, Jazan University, Jazan 45142, Saudi Arabia;
| | - Krzysztof Goniewicz
- Department of Security Studies, Polish Air Force University, 08-521 Dęblin, Poland;
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Aniort J, Trefond J, Tanguy G, Bataille S, Burtey S, Pereira B, Garrouste C, Philipponnet C, Clavelou P, Heng AE, Lautrette A. Impact of reference panel composition on scores of script concordance test assessing basic nephrology knowledge in undergraduate medical education. Med Teach 2024; 46:110-116. [PMID: 37544894 DOI: 10.1080/0142159x.2023.2239441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
PURPOSE In the assessment of basic medical knowledge, the composition of the reference panel between specialists and primary care (PC) physicians is a contentious issue. We assessed the effect of panel composition on the scores of undergraduate medical students in a script concordance test (SCT). METHODS The scale of an SCT on basic nephrology knowledge was set by a panel of nephrologists or a mixed panel of nephrologists and PC physicians. The results of the SCTs were compared with ANOVA for repeated measurements. Concordance was assessed with Bland and Altman plots. RESULTS Forty-five students completed the SCT. Their scores differed according to panel composition: 65.6 ± 9.73/100 points for nephrologists, and 70.27 ± 8.82 for the mixed panel, p < 0.001. Concordance between the scores was low with a bias of -4.27 ± 2.19 and a 95% limit of agreement of -8.96 to -0.38. Panel composition led to a change in the ranking of 71% of students (mean 3.6 ± 2.6 places). CONCLUSION The composition of the reference panel, either specialist or mixed, for SCT assessment of basic knowledge has an impact on test results and student rankings.
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Affiliation(s)
- Julien Aniort
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Hospital, Clermont-Ferrand, France
- Human Nutrition Unit, Clermont Auvergne University INRAE UMR 1019, Clermont-Ferrand, France
| | - Jeromine Trefond
- General Practitioner Department, Clermont-Ferrand Medical School, Clermont Auvergne University, Clermont-Ferrand, France
| | - Gilles Tanguy
- General Practitioner Department, Clermont-Ferrand Medical School, Clermont Auvergne University, Clermont-Ferrand, France
| | - Stanislas Bataille
- Phocean Nephrology Institute, ELSAN, Clinique Bouchard, Marseille, France
- C2VN, Aix-Marseille Univ, INSERM, INRAE UMR 1076, Marseille, France
| | - Stephane Burtey
- C2VN, Aix-Marseille Univ, INSERM, INRAE UMR 1076, Marseille, France
- Centre de Néphrologie et Transplantation Rénale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Bruno Pereira
- Biostatistics Unit, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Cyril Garrouste
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Carole Philipponnet
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Pierre Clavelou
- Neuro-Dol, INSERM, CHU Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Anne-Elisabeth Heng
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Hospital, Clermont-Ferrand, France
- Human Nutrition Unit, Clermont Auvergne University INRAE UMR 1019, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Intensive Care Unit, Centre Jean Perrin, Clermont-Ferrand, France
- LMGE (Laboratoire MicroOrganisme Genome et Environnement), Clermont Auvergne University CNRS UMR 6023, Clermont-Ferrand, France
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Donroe JH, Egger E, Soares S, Sofair AN. Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases. Cureus 2024; 16:e51696. [PMID: 38313894 PMCID: PMC10838525 DOI: 10.7759/cureus.51696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers. Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.
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Affiliation(s)
- Joseph H Donroe
- General Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Emilie Egger
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, USA
| | - Sarita Soares
- General Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Andre N Sofair
- General Internal Medicine, Yale School of Medicine, New Haven, USA
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Holm A, Rodkjær LØ, Bekker HL. Integrating Patient Involvement Interventions within Clinical Practice: A Mixed-Methods Study of Health Care Professional Reasoning. MDM Policy Pract 2024; 9:23814683241229987. [PMID: 38362059 PMCID: PMC10868494 DOI: 10.1177/23814683241229987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/13/2024] [Indexed: 02/17/2024] Open
Abstract
Background. Patient involvement interventions are complex interventions that improve patient involvement in treatment and care in health care systems. Studies report several benefits of patient involvement interventions and that health care professionals are positive about using them. However, they have not been explored as a collected group of interventions throughout the continuum of care and treatment. In addition, the relationship between patient involvement interventions and the clinical reasoning process of health care professionals has not been thoroughly studied. Design. This mixed-methods study was conducted at Aarhus University Hospital in Denmark between April and November 2022 using interview data from 12 health care professionals and survey data from 420 health care professionals. Informants were medical doctors, nurses, midwives, dietitians, physiotherapists, and occupational therapists who had direct contact with patients during their daily care and treatment. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed via inductive and deductive content analysis. Results. Communication and interaction were seen as overarching aspects of patient involvement, with patient involvement interventions being defined as concrete tools and methods to enhance health care professionals' explicit clinical reasoning process. Limitations. It is unclear if results are representative of all health care professionals at the hospital or only those with a positive view of patient involvement interventions. Conclusions. Patient involvement interventions are viewed as beneficial for patients and fit with the clinical reasoning of health care professionals. Clinical reasoning may be an active ingredient in the development and implementation of patient involvement interventions. Implications. In practice, health care professionals need training in person-centered communication and the ability to articulate their clinical reasoning explicitly. In research, a more in-depth understanding of the interrelations between patient involvement interventions and clinical reasoning is needed. Highlights Communication and interaction are the fundamental goals of patient involvement in practice, regardless of which patient involvement intervention is being used.Clinical reasoning is often an unconscious process using tacit knowledge, but the use of patient involvement interventions may be a way for health care professionals (at both individual and group levels) to become more explicit about and aware of their reflections.Clinical reasoning can be viewed as a mechanism of change in the development and implementation of patient involvement interventions.
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Affiliation(s)
- Anna Holm
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Department of Intensive Care, Aarhus University Hospital, Denmark
| | - Lotte Ørneborg Rodkjær
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Department of Infectious Disease, Aarhus University Hospital, Denmark
| | - Hilary Louise Bekker
- Research Centre for Patient Involvement, Department of Public Health, Aarhus University and Aarhus University Hospital, Denmark
- Leeds Unit of Complex Intervention Development (LUCID), Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
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Hosseinzadeh T, Mirfarhadi N, Pouralizadeh M, Tabrizi KN, Fallahi‐Khoshknab M, Khankeh HR, Shokooh F. Psychometric properties of the persian version of the nursing clinical reasoning scale. Nurs Open 2024; 11:e2041. [PMID: 38268299 PMCID: PMC10697119 DOI: 10.1002/nop2.2041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 01/26/2024] Open
Abstract
AIM The aim of this study was to translate the Nursing Clinical Reasoning Scale (NCRS) into Persian and evaluate its psychometric properties. DESIGN This study was a methodological and cross-sectional study. METHODS This methodological study was conducted in 2020 in a teaching hospital. After obtaining necessary permission from its developers, NCRS was translated into Persian through the method proposed by the World Health Organization. Then, its face, content, and construct validity and reliability were assessed. For construct validity assessment through exploratory and confirmatory factor analyses, 300 nurses (two 150-nurse samples), who had randomly been selected, completed the instrument. Reliability also assessed through the internal consistency and the stability methods. Data were analysed using the SPSS (v. 20.0) and the AMOS (v. 5.0) software. RESULTS The content validity indices of NCRS and its items were 0.97 and more than 0.79, respectively. Exploratory factor analysis revealed an assessment and confirmation factor and an implementation and reflection factor for the scale which together explained 57.30% of the total variance. Confirmatory factor analysis also confirmed this two-factor structure (χ2 /df = 2.11, NNFI = 0.952, RMSEA = 0.053, CFI = 0.91, GFI = 0.94, IFI = 0.95, and NFI = 0.96). The Cronbach's alpha and the intraclass correlation coefficient values of the scale were 0.96 and 0.94, respectively. PUBLIC CONTRIBUTION The Persian NCRS can help nursing policy makers and mentors identify the need for developing nurses' and nursing students' CR skills and implement need-based educational courses to improve these skills. Moreover, it helps determine whether the educational programmes are effective in improving nurses' CR skills and clinical competence.
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Affiliation(s)
- Touba Hosseinzadeh
- School of Nursing and MidwiferyGuilan University of Medical Science (GUMS)RashtIran
| | - Nastaran Mirfarhadi
- School of Nursing and MidwiferyGuilan University of Medical Science (GUMS)RashtIran
| | - Moluk Pouralizadeh
- School of Nursing and MidwiferyGuilan University of Medical Science (GUMS)RashtIran
| | - Kian Norouzi Tabrizi
- Department of Nursing, Social Determinants of Health Research CenterUniversity of Social Welfare and Rehabilitation SciencesTehranIran
| | | | - Hamid reza Khankeh
- Department of Health in Disasters & EmergenciesUniversity of Social Welfare and Rehabilitation SciencesTehranIran
| | - Forozan Shokooh
- Department of Basic SciencesUniversity of Social Welfare and Rehabilitation SciencesTehranIran
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Zanconato L, Rossettini G, Mourad F, Cotrozzi M, Carità E, Di Filippo L, Turolla A, Smania N, Picelli A, Valè N, Maselli F. Ewing's sarcoma in a young man mimicking lateral elbow pain: A case report with 2 years follow-up. Physiother Res Int 2024; 29:e2063. [PMID: 37937470 DOI: 10.1002/pri.2063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/10/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND AND PURPOSE Lateral elbow pain represents a common musculoskeletal disorder, mostly non-specific and benign. In rare cases, it can be the first symptom of a severe disease such as Ewing's sarcoma (ES). ES is the second most common primary malignant bone tumor in the young population, with a high probability of an unfavourable prognosis. CASE PRESENTATION This case report presents the history of a young man presenting to the physical therapist with a diagnosis of "epicondylitis" in the right elbow, which was later revealed to be an aggressive ES of the ulna. Findings raising clinical doubts were (a) constant pain even at night and not dependent on load, (b) significant loss of function, (c) patient's young age, and (d) a palpable mass in the elbow. RESULTS After diagnosis, the patient received medical (chemotherapy, radiotherapy and surgery) and a rehabilitation program. After treatment, the patient improved elbow function, decreased disability and returned to social participation, maintaining positive outcomes at the 2-year follow-up. DISCUSSION In summary, this case report emphasizes the importance of differential diagnosis and screening for referral of red flags in physical therapy. Moreover, it describes the rehabilitation of a patient with ES, enriching the scientific literature in the field.
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Affiliation(s)
| | | | - Firas Mourad
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg
- Luxembourg Health & Sport Sciences Research Institute A.s.b.l., Differdange, Luxembourg
| | | | | | - Luigi Di Filippo
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Turolla
- Division of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nicola Smania
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
- Canadian Advances in Neuro-Orthopaedics for Spasticity Congress (CANOSC), Kingston, Ontario, Canada
| | - Nicola Valè
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
| | - Filippo Maselli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Österholm J, Larsson Ranada Å. Occupational therapists' experiences of working with people with dementia: a qualitative study. Scand J Occup Ther 2024; 31:2305253. [PMID: 38277243 DOI: 10.1080/11038128.2024.2305253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/10/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Dementia is an age-related disease associated with complex health and care needs. Due to demographical shifts, the number of older people with dementia is forecasted to increase. Occupational therapists encounter people with dementia in their daily work, yet little is known about their experience of working with people with dementia. AIM/OBJECTIVES To explore occupational therapist's experiences of working with people with dementia. MATERIAL AND METHODS Ten occupational therapists were interviewed using semi-structured interviews. Data were analysed using reflexive thematic analysis. RESULTS The results are presented in five different themes: Working with persons who do not recognise decline in their abilities; Saving-face of the person in assessment situations; Facilitating continued engagement in everyday activities; Utilising information provided by care staff; Balancing different preferences on how to proceed. CONCLUSION Occupational therapists perceive a need in their work to employ various face-saving strategies and facilitate engagement in everyday activities. The results are exploratory and additionally research is needed to understand the therapists' experiences of working with persons with dementia. SIGNIFICANCE Everyday activities should be tailored to the person's abilities, with an emphasis on facilitating the person in carrying them out rather than the social environment taking them over.
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Affiliation(s)
- Johannes Österholm
- Unit of Occupational Therapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Åsa Larsson Ranada
- Unit of Occupational Therapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Pérez-Perdomo A, Zabalegui A. Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials. Healthcare (Basel) 2023; 12:90. [PMID: 38200996 PMCID: PMC10779280 DOI: 10.3390/healthcare12010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Clinical reasoning (CR) is a holistic and recursive cognitive process. It allows nursing students to accurately perceive patients' situations and choose the best course of action among the available alternatives. This study aimed to identify the randomised controlled trials studies in the literature that concern clinical reasoning in the context of nursing students. METHODS A comprehensive search of PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) was performed to identify relevant studies published up to October 2023. The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary study aim; (b) articles published for the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) Randomised Clinical Trials. The Critical Appraisal Skills Programme tool was utilised to appraise all included studies. RESULTS Fifteen papers were analysed. Based on the teaching strategies used in the articles, two groups have been identified: simulation methods and learning programs. The studies focus on comparing different teaching methodologies. CONCLUSIONS This systematic review has detected different approaches to help nursing students improve their reasoning and decision-making skills. The use of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students' reasoning skills. Nursing schools should evaluate their current methods and consider integrating or modifying new technologies and methodologies that can help enhance students' learning and improve their clinical reasoning and cognitive skills.
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Diaz CM, Egide A, Berry A, Rafferty M, Amro A, Tesorero K, Shapiro M, Ko B, Jones W, Slocum JD, Johnson J, Stey AM. Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study. BMJ Open 2023; 13:e075470. [PMID: 38097232 PMCID: PMC10729088 DOI: 10.1136/bmjopen-2023-075470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN An observational cross-sectional qualitative study. SETTING A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME Conditions for effective interdisciplinary care team communication. RESULTS We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.
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Affiliation(s)
| | - Abahuje Egide
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Andrew Berry
- Department of Medical Social Sciences, Northwestern University, Evanston, Illinois, USA
| | - Miriam Rafferty
- 19th floor Strength+Endurance AbilityLab, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation & Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ali Amro
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | | | - Michael Shapiro
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Bona Ko
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Whitney Jones
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - John D Slocum
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Julie Johnson
- Department of Surgery, Northwestern University, Evanston, Illinois, USA
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Deschênes MF, Fernandez N, Lechasseur K, Caty MÈ, Azimzadeh D, Mai TC, Lavoie P. Transformation and Articulation of Clinical Data to Understand Students' and Health Professionals' Clinical Reasoning: Protocol for a Scoping Review. JMIR Res Protoc 2023; 12:e50797. [PMID: 38090795 PMCID: PMC10753415 DOI: 10.2196/50797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/02/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND There are still unanswered questions regarding effective educational strategies to promote the transformation and articulation of clinical data while teaching and learning clinical reasoning. Additionally, understanding how this process can be analyzed and assessed is crucial, particularly considering the rapid growth of natural language processing in artificial intelligence. OBJECTIVE The aim of this study is to map educational strategies to promote the transformation and articulation of clinical data among students and health care professionals and to explore the methods used to assess these individuals' transformation and articulation of clinical data. METHODS This scoping review follows the Joanna Briggs Institute framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist for the analysis. A literature search was performed in November 2022 using 5 databases: CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and Web of Science (Clarivate). The protocol was registered on the Open Science Framework in November 2023. The scoping review will follow the 9-step framework proposed by Peters and colleagues of the Joanna Briggs Institute. A data extraction form has been developed using key themes from the research questions. RESULTS After removing duplicates, the initial search yielded 6656 results, and study selection is underway. The extracted data will be qualitatively analyzed and presented in a diagrammatic or tabular form alongside a narrative summary. The review will be completed by February 2024. CONCLUSIONS By synthesizing the evidence on semantic transformation and articulation of clinical data during clinical reasoning education, this review aims to contribute to the refinement of educational strategies and assessment methods used in academic and continuing education programs. The insights gained from this review will help educators develop more effective semantic approaches for teaching or learning clinical reasoning, as opposed to fragmented, purely symptom-based or probabilistic approaches. Besides, the results may suggest some ways to address challenges related to the assessment of clinical reasoning and ensure that the assessment tasks accurately reflect learners' developing competencies and educational progress. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50797.
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Affiliation(s)
| | | | | | - Marie-Ève Caty
- Département d'orthophonie, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Dina Azimzadeh
- Faculté des sciences infirmières, Université de Montréal, Montréal, QC, Canada
| | - Tue-Chieu Mai
- Faculté des sciences infirmières, Université de Montréal, Montréal, QC, Canada
| | - Patrick Lavoie
- Faculté des sciences infirmières, Université de Montréal, Montreal, QC, QC, Canada
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Hage R, Roussel N, Dierick F, Da Natividade J, Jones M, Fourré A. Rethinking neck-related arm pain: hypothetical clinical scenarios to differentiate the underlying IASP-defined pain mechanisms. J Man Manip Ther 2023:1-12. [PMID: 38087995 DOI: 10.1080/10669817.2023.2292909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023] Open
Abstract
Neck-related arm pain is frequently encountered in clinical settings, yet its underlying pain mechanisms remain elusive. While such pain radiating from the neck to the arm is often attributed to injuries or diseases of the nervous system (neuropathic pain), it can also arise from nociceptive (referred) or nociplastic sources. Regrettably, patients exhibiting this specific pain distribution are frequently diagnosed with varying terms, including 'cervicobrachialgia', 'cervicobrachial neuralgia', 'cervicobrachial pain syndrome', and 'cervical radiculopathy'. The ambiguity surrounding these diagnostic labels complicates the clinical reasoning process. It is imperative for clinicians to discern and comprehend the dominant pain mechanism. Three distinct hypothetical clinical scenarios depict patients with almost identical pain distribution but divergent dominant pain mechanisms. Within these scenarios, both subjective and objective examinations are employed to elucidate the dominant pain mechanism associated with neck-related arm pain: nociceptive, neuropathic, and nociplastic. Furthermore, clinicians must remain aware that the dominant pain mechanism can evolve over time.
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Affiliation(s)
- Renaud Hage
- Traitement Formation Thérapie Manuelle (TFTM), Manual Therapy Center, Brussels, Belgium
- CeREF Technique, Haute Ecole Louvain en Hainaut, Mons, Belgium
- Faculté des Sciences de la Motricité, UCLouvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Nathalie Roussel
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium
| | - Frédéric Dierick
- Faculté des Sciences de la Motricité, UCLouvain, Ottignies-Louvain-la-Neuve, Belgium
- Laboratoire d'Analyse du Mouvement et de la Posture (LAMP), Centre National de Rééducation Fonctionnelle et de Réadaptation - Rehazenter, Luxembourg, Luxembourg
| | - Joël Da Natividade
- Laboratoire d'Analyse du Mouvement et de la Posture (LAMP), Centre National de Rééducation Fonctionnelle et de Réadaptation - Rehazenter, Luxembourg, Luxembourg
| | - Mark Jones
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Antoine Fourré
- Traitement Formation Thérapie Manuelle (TFTM), Manual Therapy Center, Brussels, Belgium
- Faculté des Sciences de la Motricité, UCLouvain, Ottignies-Louvain-la-Neuve, Belgium
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium
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Bernal-Bello D, Lara-Montes C, Jaenes-Barrios B. COVID-19? Let me see your hands. J R Coll Physicians Edinb 2023; 53:269-271. [PMID: 37850435 DOI: 10.1177/14782715231206530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
During the first wave of the COVID�19 pandemic, a patient with anti-synthetase syndrome (ASS) was misdiagnosed as having bilateral severe acute respiratory syndrome coronavirus 2 pneumonia on admission. A comprehensive clinical evaluation would have led to the correct diagnosis earlier, as he had some data consistent with ASS on both physical examination and laboratory tests that were initially overlooked. In addition, a malignant lesion in the colon was found on screening for underlying malignancy. In this context, ASS has been considered a low-risk subgroup for cancer among idiopathic inflammatory myopathies. However, this should be interpreted cautiously and should not lead to neglect of adequate cancer screening adjusted for age, sex and other potential risk factors.
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Affiliation(s)
- David Bernal-Bello
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Celia Lara-Montes
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
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Paul A, Leung D, Salas RME, Cruz TE, Abras C, Saylor D, Gugliucciello V, Nunn J, Gamaldo CE, Strowd RE. Comparative effectiveness study of flipped classroom versus online-only instruction of clinical reasoning for medical students. Med Educ Online 2023; 28:2142358. [PMID: 36333903 PMCID: PMC9645276 DOI: 10.1080/10872981.2022.2142358] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
CONTEXT Bedside clinical teaching is the backbone of clerkship education. Data-driven methods for supplementing bedside encounters with standardized content from vetted resources are needed. OBJECTIVE To compare a flipped-classroom versus an interactive online-only instruction for improving knowledge, skills, self-directed learning (SDL) behaviors, and satisfaction in a medical school clerkship. METHODS An IRB-approved prospective study employing a peer-reviewed clinical reasoning curriculum in neurology was conducted; 2nd-4th year medical students rotating through a required clerkship were enrolled. Students were randomized to flipped-classroom (i.e., flipped) or interactive asynchronous online instruction (i.e., online-only), which supplemented existing bedside teaching. Baseline and end-of-course knowledge, skill development, SDL behaviors, satisfaction, and long-term retention were assessed by peer-reviewed clinical reasoning exam, NBME scores, faculty/resident clinical evaluations, non-compulsory assignment completion, end-of-clerkship surveys, and objective structured clinical exam (OSCE). RESULTS 104 students (49 flipped, 55 online-only) were enrolled. Age, gender, and training level did not differ by group (all p > 0.43); baseline knowledge was higher in the flipped group (p = 0.003). Knowledge-based exam scores did not differ by group even after adjusting for differences in baseline knowledge (2.3-points higher in flipped group, 95%CI -0.4-4.8, p = 0.07). Clinical skills were significantly higher in the flipped group, including examination skills (4.2 ± 0.5 vs. 3.9 ± 0.7, p = 0.03) and future housestaff potential (4.8 ± 0.3 vs 4.5 ± 0.6, p = 0.03). Students in the online-only group were more likely to engage in SDL (42 vs. 12%, p = 0.001) and reported more hours studying (6.1 vs. 3.8 hours, p = 0.03). Satisfaction (p = 0.51) and OSCE scores (p = 0.28) were not different by group. CONCLUSIONS In this comparative study of two evidence-based curricular delivery approaches, we observed no difference in knowledge acquired. Greater clinical skills were observed with flipped instruction, while more SDL was observed with online-only instruction. Supplementing bedside teaching with blended instruction that balances live skill development with vetted online resources is optimal for clerkship education.
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Affiliation(s)
- Ashley Paul
- Department of Neurology, Johns Hopkins School of Medicine, 21287, Baltimore, MD, USA
| | - Doris Leung
- Department of Neurology, Johns Hopkins School of Medicine, 21287, Baltimore, MD, USA
| | - Rachel Marie E Salas
- Department of Neurology, Johns Hopkins School of Medicine, 21287, Baltimore, MD, USA
| | - Tiana E Cruz
- The Counseling Center, University of Maryland, College Park, 20742, MD, USA
| | - Chadia Abras
- Office of the Provost, Johns Hopkins University, 21218, Baltimore, MD, USA
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins School of Medicine, 21287, Baltimore, MD, USA
| | - Veronique Gugliucciello
- Center for Technology in Education, Johns Hopkins School of Education, 21218, Baltimore, MD, USA
| | - Jaqueline Nunn
- Center for Technology in Education, Johns Hopkins School of Education, 21218, Baltimore, MD, USA
| | - Charlene E Gamaldo
- Department of Neurology, Johns Hopkins School of Medicine, 21287, Baltimore, MD, USA
| | - Roy E Strowd
- Department of Neurology, Wake Forest School of Medicine, 27104, Winston Salem, NC, USA
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Elbi H, Tan MN, Yokus SE, Ozcan F, Mevsim V, Stolper E. The linguistic validation of the gut feelings questionnaire in Turkish. Eur J Gen Pract 2023; 29:2273846. [PMID: 37929745 PMCID: PMC10629413 DOI: 10.1080/13814788.2023.2273846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND 'Gut feelings' are frequently used by general practitioners in the clinical decision-making process, especially in situations of uncertainty. The Gut Feelings Questionnaire (GFQ) has been developed in the Netherlands and is now available in English, French, German, Polish, Spanish, and Catalan, enabling cross-border studies on the subject. However, a Turkish version of the GFQ is lacking. OBJECTIVES A Turkish version of the GFQ. METHODS A linguistic validation procedure was conducted, which took place in six phases: forward translation (step 1), backward translation (step 2), first consensus (step 3), cultural validation (step 4), second consensus (step 5), and final version (step 6). RESULTS The absence of literal equivalent of the term 'gut feelings' in Turkish was determined. The word 'intuition' was chosen as the Turkish literal equivalent of 'gut feelings'. There were also some challenges in finding the exact meanings of words and expressions in Turkish literature. However, we succeeded in finding adequate and responsible solutions. A Turkish version of the GFQ is available now. CONCLUSION With these validated GFQs, Turkish GPs can facilitate studies of the role of 'gut feelings' in clinical reasoning.
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Affiliation(s)
- Huseyin Elbi
- Department of Family Medicine, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Makbule Neslişah Tan
- Department of Family Medicine, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Sidika Ece Yokus
- Department of Family Medicine, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Fatih Ozcan
- Department of Family Medicine, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Vildan Mevsim
- Department of Family Medicine, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Erik Stolper
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
- Faculty of Medicine and Health Sciences, Department of Family Medicine and Population Health, University of Antwerp Antwerp, Belgium, Antwerp, Belgium
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Rossettini G, Cook C, Palese A, Pillastrini P, Turolla A. Pros and Cons of Using Artificial Intelligence Chatbots for Musculoskeletal Rehabilitation Management. J Orthop Sports Phys Ther 2023; 53:1-7. [PMID: 37707390 DOI: 10.2519/jospt.2023.12000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
SYNOPSIS: Artificial intelligence (AI), specifically large language models (LLMs), which focus on the interaction between computers and human language, can influence musculoskeletal rehabilitation management. AI chatbots (eg, ChatGPT, Microsoft Bing, and Google Bard) are a form of large language models designed to understand, interpret, and generate text similar to what is produced by humans. Since their release, chatbots have triggered controversy in the international scientific community, including when they have passed university exams, generated credible scientific abstracts, and shown potential for replacing humans in scientific roles. The controversies extend to the field of musculoskeletal rehabilitation. In this Viewpoint, we describe the potential applications and limitations, and recommended actions for education, clinical practice, and research when using AI chatbots for musculoskeletal rehabilitation management, aspects that may have similar implications for the broader health care community. J Orthop Sports Phys Ther 2023;53(12):1-7. Epub 14 September 2023. doi:10.2519/jospt.2023.12000.
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Begun YS, Stange LR, Davis CR. Script concordance testing in genetic counseling training: A pilot study. J Genet Couns 2023; 32:1121-1130. [PMID: 37443441 DOI: 10.1002/jgc4.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/28/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023]
Abstract
Clinical reasoning is a complex skill that represents a trainee's ability to use their professional knowledge and skills to assess and solve the problems that arise in clinical practice. As an integral tenet of the genetic counseling process, clinical reasoning skills underlie many of the Practice-Based Competencies (2019) across a variety of domains. Despite the long-lasting recognition of the importance of this complex skill in the training of genetic counselors, clinical reasoning has traditionally been difficult to assess in a standardized way in healthcare education. Script concordance testing is a standardized method of assessing clinical reasoning skills in ambiguous clinical situations. The tool has been used to successfully measure the clinical reasoning skills of trainees in various healthcare training programs and has never been used in a genetic counseling training program. We conducted a pilot study to assess the utility of script concordance testing in the field of genetic counseling as an objective measure of clinical reasoning in trainees. The script concordance test was constructed for the field of genetic counseling and administered to 22 second year genetic counseling students in the Joan H. Marks Graduate Program in Human Genetics at Sarah Lawrence College. Twelve genetic counselors served on a panel to provide expert clinical reasoning responses and a scoring grid was developed using the aggregate scores method. The utility of the tool was measured using Cronbach's alpha coefficient, and scores of students and the panel were compared using Hedge's g. Results revealed statistically significant differences between the scores of panelists and students and good reliability. This study shows that script concordance testing can be used to measure clinical reasoning skills in genetic counseling trainees in a way that is reliable, standardized, and easy to use, thereby allowing programs to better assess the clinical reasoning skills of trainees prior to graduation.
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Affiliation(s)
- Yakira S Begun
- Sarah Lawrence College Joan H. Marks Graduate Program in Human Genetics, Bronxville, New York, USA
| | - Lila R Stange
- Sarah Lawrence College Joan H. Marks Graduate Program in Human Genetics, Bronxville, New York, USA
| | - Claire R Davis
- Sarah Lawrence College Joan H. Marks Graduate Program in Human Genetics, Bronxville, New York, USA
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Milani A, Misurelli E, Bottaccioli AG, Bottaccioli F, Lacapra S, Ciccarelli C, Magon G, Mazzocco K. The iceberg of genomics: New perspectives in the use of genomics and epigenetics in oncology nursing clinical reasoning. A discursive paper. J Adv Nurs 2023; 79:4560-4567. [PMID: 37705490 DOI: 10.1111/jan.15858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Although, there is a wealth of information in the medical literature on the usefulness of genomic testing in assessing risk and its application in medical oncology decision making, there are no theoretical reflections in the nursing field. AIM To understand the implications of molecular biology in nursing practice and highlight the role of Nursing Theory in guiding nurses' reasoning. MATERIALS AND METHODS Searching literature published between 2000 and 2022 in Medline and Google Scholar. Scientific evidence was analysed by the authors expert in different fields. RESULTS Based on the findings of the literature, concerns have been raised about the proper care of cancer patients who have a genomic risk profile determination. In particular, the absence of theoretical thinking and conceptual models that consider developments in molecular biology and their impact on nursing, in addition to the prevalence of heuristic thinking and the application of clinical patterns in nursing practice, could induce patient misjudgement with inadequate planning of preventive, curative, rehabilitative and educational nursing interventions. Nurses working in the field of oncology should be aware that the risk profile determined by genomics tests is merely the visible and stated portion of the cancer patient: the tip of iceberg. DISCUSSION This study demonstrates how genomic testing takes into account a fraction of genes discovered in tumour tissue to establish a risk profile. This subset differs, for example, from the social genome, which can determine the risk of dementia, cancer and cardiovascular disease, but in response to social adversity. Nursing theory, which views the environment as a metaparadigm, must consider a conceptual model that can integrate the findings of genomic testing with recommendations from studies on the social genome of humans to make it easier to build nursing treatments that can better reduce these risks. CONCLUSION A nursing theoretical discourse on genomics is a paramount requirement for developing effective nursing care.
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Affiliation(s)
- Alessandra Milani
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Eliana Misurelli
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Giulia Bottaccioli
- Italian Society of Psychoneuroendocrineimmunology, Rome, Italy
- Department of Clinical Psychology, Università Vita e Salute, Milan, Italy
| | | | - Silvana Lacapra
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Chiara Ciccarelli
- School of Nursing, European Institute of Oncology IRCCS, Milan, Italy
| | - Giorgio Magon
- Nursing Manager, European Institute of Oncology IRCCS, Milan, Italy
| | - Ketti Mazzocco
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
- Division of Applied Research for Cognitive and Psychological Sciences, European Institute of Oncology IRCCS, Milan, Italy
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Mastromarchi P, McLean S, Ali N, May S. Effects of matched vs. unmatched physical therapy interventions on pain or disability in patients with neck pain - a systematic review and meta-analysis. Physiother Theory Pract 2023:1-20. [PMID: 38037765 DOI: 10.1080/09593985.2023.2285892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The interventions performed in most randomized controlled trials (RCTs) on neck pain patients are standardized, irrespective of the high heterogeneity of patients. However, clinicians tend to choose an intervention based on the patients' clinical characteristics, and thus match the treatment to the patient. OBJECTIVES To investigate the effectiveness of interventions matched to the clinical characteristics of patients with neck pain versus the same, but unmatched treatment for improving pain or disability. DESIGN A systematic review and meta-analysis conducted following Cochrane guidelines. METHODS Databases searches were performed from inception to September 2023. RCTs were included if the patients in the experimental group received a treatment matched to clinical presentation or to clinicians' assessment, if the patients in the control group received a similar but unmatched treatment, and if pain or disability were reported as outcome measures. RESULTS The literature search produced 9516 records of which 27 met the inclusion criteria. Matched exercise therapy was superior to unmatched exercise for pain (SMD -0.57; 95% CI -0.95, -0.18) and for disability (SMD -0.69; 95% CI -1.14, -0.23) at short term, but not at intermediate-term follow-up. Matched manual treatment was not superior to unmatched manual therapy for pain or for disability at short or intermediate-term follow-up. CONCLUSIONS Results suggest that matching exercise to movement limitation, trapezius myalgia, or forward head position may lead to better outcomes in the short term, but not in the intermediate-term. Matched manual therapy was not superior to unmatched treatment either short or intermediate-term. Further research is warranted to verify if those criteria are potentially useful matching criteria.
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Affiliation(s)
- Paolo Mastromarchi
- Scuola Universitaria per la Svizzera Italiana, DEASS, via Violino 11, Manno, Switzerland
- Department of Allied Health Professions, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
| | - Sionnadh McLean
- Department of Allied Health Professions, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
| | - Nancy Ali
- Department of Allied Health Professions, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
| | - Stephen May
- Centre for Applied Health and Social Care Research (CARe), College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
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Smith MP, Tracy B, Soncrant J, Young JL, Rhon DI, Cook CE. What factors do physical therapists consider when determining patient prognosis: A mixed methods study. Musculoskeletal Care 2023; 21:1412-1420. [PMID: 37712685 DOI: 10.1002/msc.1823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION A prognosis provides valuable information to expected progress and anticipated outcome over the course of care. Although it is known that physical therapists can accurately prognose, it is unknown what factors are utilised in clinical practice. OBJECTIVE The purpose of this study was to determine the prognostic domains and factors that influenced a PT's clinical reasoning processes. DESIGN Mixed Methods Design, affirming the prognostic ability of the physical therapists and the qualitative exploration of the prognostic factors considered by physical therapists. METHODS Twenty-nine physical therapists participated in this study. Participants underwent semi-structured qualitative interviews that were coded to populate a prognostic framework. In addition, de-identified patient data was used to determine the ability of the PT to form a prognosis. Linear regression was used to determine if an initial prognostic score was related to function at discharge. RESULTS There were significant relationships (p = <0.05) between the prognosis score and Focus on Therapeutic Outcomes (B = 2.25), Numeric Pain Rating Scale (B = 0.257), and GROC (B = 0.289) upon patient discharge. Qualitative factors were categorised into prognostic domains (prevalence): Mood, Motivation, Pain Behaviours (100%), Disease Severity (93.1%), Health Status (86.2%), Social, Occupation, Environmental (67.0%), and Genetics, Biology, Biomarkers (44.8%). Factors that did not fit established domains were reported and categorised as Other (86.2%). CONCLUSION Our findings support the relationship between PT prognosis of patients with musculoskeletal pain and patient outcomes. In addition, the domains and factors PTs use to formulate prognosis during evaluation present a complex biopsychosocial framework, suggesting that PTs consider factors from multiple domains when forming a prognosis.
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Affiliation(s)
- Matthew P Smith
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- Northwestern University, Department of Physical Therapy and Human Movement Sciences, Chicago, Illinois, USA
| | - Brad Tracy
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Jason Soncrant
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Jodi L Young
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Daniel I Rhon
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Chad E Cook
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- Duke University, Department of Orthopaedics, Durham, North Carolina, USA
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Toy S, Shafiei SB, Ozsoy S, Abernathy J, Bozdemir E, Rau KK, Schwengel DA. Neurocognitive Correlates of Clinical Decision Making: A Pilot Study Using Electroencephalography. Brain Sci 2023; 13:1661. [PMID: 38137109 PMCID: PMC10741622 DOI: 10.3390/brainsci13121661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
The development of sound clinical reasoning, while essential for optimal patient care, can be quite an elusive process. Researchers typically rely on a self-report or observational measures to study decision making, but clinicians' reasoning processes may not be apparent to themselves or outside observers. This study explored electroencephalography (EEG) to examine neurocognitive correlates of clinical decision making during a simulated American Board of Anesthesiology-style standardized oral exam. Eight novice anesthesiology residents and eight fellows who had recently passed their board exams were included in the study. Measures included EEG recordings from each participant, demographic information, self-reported cognitive load, and observed performance. To examine neurocognitive correlates of clinical decision making, power spectral density (PSD) and functional connectivity between pairs of EEG channels were analyzed. Although both groups reported similar cognitive load (p = 0.840), fellows outperformed novices based on performance scores (p < 0.001). PSD showed no significant differences between the groups. Several coherence features showed significant differences between fellows and residents, mostly related to the channels within the frontal, between the frontal and parietal, and between the frontal and temporal areas. The functional connectivity patterns found in this study could provide some clues for future hypothesis-driven studies in examining the underlying cognitive processes that lead to better clinical reasoning.
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Affiliation(s)
- Serkan Toy
- Departments of Basic Science Education & Health Systems and Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA;
| | - Somayeh B. Shafiei
- Intelligent Cancer Care Laboratory, Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
| | | | - James Abernathy
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA;
| | - Eda Bozdemir
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520, USA;
| | - Kristofer K. Rau
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016, USA;
| | - Deborah A. Schwengel
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA;
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Cunha LDM, Pestana-Santos M, Lomba L, Santos MR. "A Certainty for you Does Not Mean That it is a Certainty for Science": A Phenomenological Analysis of Experiences of Uncertainty in Clinical Reasoning of Nurses in the Postanesthesia Care Unit. J Perianesth Nurs 2023:S1089-9472(23)00943-7. [PMID: 37978973 DOI: 10.1016/j.jopan.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To explore the experiences of uncertainty in the clinical reasoning of nurses in the postanesthesia care unit (PACU). DESIGN A phenomenological descriptive design, following Colaizzi's analysis. METHODS Semistructured interviews were conducted with 14 nurses from a PACU on their experience of uncertainty in clinical reasoning. The interviews were digitally audio-recorded and transcribed verbatim. Two researchers conducted data analysis independently and followed seven phases: (re)reading the transcripts, extracting significant statements, formulating meanings from significant statements, aggregating formulated meanings into themes, developing a description of the phenomenon's essential structure, generating of the fundamental structure of the phenomenon, validating of the findings through participant feedback. The process employed MAXQDA analytics Pro 2022 software. Consolidated Criteria for Reporting A Qualitative Research checklist was used for reporting. FINDINGS From uncertainty experiences in nurses' clinical reasoning, 10 themes emerged: ambiguity and decision latitude, communication, work ethic, difficulty interpreting and predicting outcomes, cognitive performance impairment, incivility, core competence vagueness of postanesthesia nurses, high-tech care, (in)security and risk, and occupational stress. CONCLUSIONS The experiences of uncertainty in clinical reasoning of nurses in postanesthesia care units are highly focused on patient safety. Exploring these experiences has made uncertainty more tangible and explicit, which will enable nurses in postanesthesia care units to prepare for adaptive responses to deal with uncertainty when it occurs in clinical practice.
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Affiliation(s)
- Lara D M Cunha
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal; Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal.
| | - Márcia Pestana-Santos
- Scientific-Pedagogical Child and Adolescent Health Nursing Department, Nursing School of Coimbra (ESEnfC), Coimbra, Portugal; Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Lurdes Lomba
- Scientific-Pedagogical Child and Adolescent Health Nursing Department, Nursing School of Coimbra (ESEnfC), Coimbra, Portugal; Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Margarida R Santos
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal; Scientific-Pedagogical Child and Adolescent Health Nursing Department, Nursing School of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS@RISE), Porto, Portugal
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Pađen L, Pajnič M, Vettorazzi R, Pérez-Perdomo A, Stefaniak M, Claes N, Franco H, Vandervoort A, Ravljen M. "Learning a Way of Thinking"-World Café on Clinical Reasoning in Nursing and Midwifery Education and Practice across Five European Union Countries. Healthcare (Basel) 2023; 11:2969. [PMID: 37998462 PMCID: PMC10671496 DOI: 10.3390/healthcare11222969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
Clinical reasoning is a key attribute of nursing and midwifery professionals. As a part of the Erasmus plus project, we designed a study with the aim of exploring the understanding of clinical reasoning as a concept, experiences of teaching clinical reasoning and practices related to using clinical reasoning in nursing and midwifery. A qualitative study was carried out using the World Café method, involving 44 participants from five European countries. The participants represented diverse professional backgrounds, including nurses, midwives and lecturers. Our analytical approach was based on a thematic analysis. We categorized the data into three main categories, namely, "Spiral of thinking", "The learning and teaching of a way of thinking" and "Clinical reasoning in real life", all under an overarching theme, "Learning a way of thinking". This study highlighted areas of learning and teaching which can be improved in current nursing and midwifery education. Furthermore, it identified barriers, facilitators and practices from five European countries which can be used in the further development of nursing and midwifery curricula and courses with the aim of enhancing clinical reasoning competence and ultimately improving patient care.
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Affiliation(s)
- Ljubiša Pađen
- Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia; (L.P.); (M.P.); (R.V.)
| | - Manca Pajnič
- Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia; (L.P.); (M.P.); (R.V.)
| | - Renata Vettorazzi
- Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia; (L.P.); (M.P.); (R.V.)
| | | | - Małgorzata Stefaniak
- Faculty of Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Nele Claes
- HBO Verpleegkunde Genk, 3600 Genk, Belgium;
| | - Hugo Franco
- School of Health Setúbal, Setúbal Polytechnic University, 2910-761 Setúbal, Portugal;
| | | | - Mirjam Ravljen
- Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia; (L.P.); (M.P.); (R.V.)
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