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Khammissa RAG, Nemutandani S, Shangase SL, Feller G, Lemmer J, Feller L. The burnout construct with reference to healthcare providers: A narrative review. SAGE Open Med 2022; 10:20503121221083080. [PMID: 35646362 PMCID: PMC9133861 DOI: 10.1177/20503121221083080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
Burnout syndrome is a psychological response to long-term exposure to occupational stressors. It is characterized by emotional exhaustion, cognitive weariness and physical fatigue, and it may occur in association with any occupation, but is most frequently observed among professionals who work directly with people, particularly in institutional settings. Healthcare professionals who work directly with patients and are frequently exposed to work overload and excessive clinical demands, to ethical dilemmas, to pressing occupational schedules and to managerial challenges; who have to make complex judgements and difficult decisions; and who have relatively little autonomy over their job-related tasks are at risk of developing clinical burnout. In turn, clinical burnout among clinicians has a negative impact on the quality and safety of treatment, and on the overall professional performance of healthcare systems. Healthcare workers with burnout are more likely to make mistakes and to be subjected to medical malpractice claims, than do those who are burnout-naïve. Experiencing the emotional values of autonomy, competence and relatedness are essential work-related psychological needs, which have to be satisfied to promote feelings of self-realization and meaningfulness in relation to work activities, thus reducing burnout risk. Importantly, an autonomy-supportive rather than a controlling style of management decreases burnout risk and promotes self-actualization, self-esteem and a general feeling of well-being in both those in charge and in their subordinates. The purpose of this article is to discuss some of the elements constituting the burnout construct with the view of gaining a better understanding of the complex multifactorial nature of burnout. This may facilitate the development and implementation of both personal, behavioural and organizational interventions to deal with the burnout syndrome and its ramifications.
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Affiliation(s)
- Razia AG Khammissa
- School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Simon Nemutandani
- School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | | | - Gal Feller
- Department of Radiation Oncology, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Johan Lemmer
- School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Liviu Feller
- School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Representation, interaction and interpretation. Making sense of the context in clinical reasoning. MEDICAL EDUCATION 2022; 56:98-109. [PMID: 33932248 DOI: 10.1111/medu.14545] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/06/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised. AIMS Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning. DISCUSSION We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning. CONCLUSION The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Feller L, Lemmer J, Nemutandani MS, Ballyram R, Khammissa RAG. Judgment and decision-making in clinical dentistry. J Int Med Res 2021; 48:300060520972877. [PMID: 33249958 PMCID: PMC7708710 DOI: 10.1177/0300060520972877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The development of clinical judgment and decision-making skills is complex, requiring clinicians—whether students, novices, or experienced practitioners—to correlate information from their own experience; from discussions with colleagues; from attending professional meetings, conferences and congresses; and from studying the current literature. Feedback from treated cases will consolidate retention in memory of the complexities and management of past cases, and the conversion of this knowledge base into daily clinical practice. The purpose of this narrative review is to discuss factors related to clinical judgment and decision-making in clinical dentistry and how both narrative, intuitive, evidence-based data-driven information and statistical approaches contribute to the global process of gaining clinical expertise.
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Affiliation(s)
- Liviu Feller
- Office of the Chair of School, School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Johan Lemmer
- Department of Oral Medicine and Periodontology, School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbulaheni Simon Nemutandani
- Chair of School of Oral Health Sciences. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raoul Ballyram
- Department of Periodontology and Oral Medicine, 37715Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Razia Abdool Gafaar Khammissa
- Department of Periodontics and Oral Medicine, School of Oral Health Sciences, Faculty of Health Sciences. 56410University of Pretoria, Pretoria, South Africa
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract 2021; 27:438-450. [PMID: 32573080 DOI: 10.1111/jep.13432] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion. AIMS AND OBJECTIVES We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses. METHODS A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review. RESULTS A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described. CONCLUSIONS Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments. Ann Emerg Med 2019; 75:206-217. [PMID: 31474478 DOI: 10.1016/j.annemergmed.2019.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature. METHODS We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included. RESULTS Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent. CONCLUSION Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.
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Huhn K, Gilliland SJ, Black LL, Wainwright SF, Christensen N. Clinical Reasoning in Physical Therapy: A Concept Analysis. Phys Ther 2019; 99:440-456. [PMID: 30496522 DOI: 10.1093/ptj/pzy148] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/29/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research. OBJECTIVE The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research. DESIGN/METHODS The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified. RESULTS Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management. LIMITATIONS Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded. CONCLUSIONS A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.
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Affiliation(s)
- Karen Huhn
- School of Physical Therapy, Husson University, Bangor, ME 04401-2999 (USA)
| | | | - Lisa L Black
- Department of Physical Therapy, Creighton University, Omaha, Nebraska
| | - Susan F Wainwright
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicole Christensen
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
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Chin-Yee B, Fuller J. Clinical judgement: Multidisciplinary perspectives. J Eval Clin Pract 2018; 24:635-637. [PMID: 29691965 DOI: 10.1111/jep.12931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Jonathan Fuller
- Toronto Philosophy of Medicine and Healthcare Network, University of Toronto, Toronto, Canada
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Chin-Yee B, Upshur R. Clinical judgement in the era of big data and predictive analytics. J Eval Clin Pract 2018; 24:638-645. [PMID: 29237237 DOI: 10.1111/jep.12852] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/18/2022]
Abstract
Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data-driven, mathematical approaches which we contrast with narrative, virtue-based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue-based clinical reasoning will remain indispensable in an era of big data and predictive analytics.
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Affiliation(s)
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Elstein AS. Revisiting 'Measuring the process of solving clinical diagnostic problems'. MEDICAL EDUCATION 2016; 50:155-159. [PMID: 26812991 DOI: 10.1111/medu.12804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Cervellin G, Borghi L, Lippi G. Do clinicians decide relying primarily on Bayesians principles or on Gestalt perception? Some pearls and pitfalls of Gestalt perception in medicine. Intern Emerg Med 2014; 9:513-9. [PMID: 24610565 DOI: 10.1007/s11739-014-1049-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
Clinical judgment is a foundation of medical practice and lies at the heart of a physician's knowledge, expertise and skill. Although clinical judgment is an active part of all medical fields, thus including diagnosis and therapy, communication and decision making, it is still poorly defined. It can be considered a synthesis of intuition (mainly based on Gestalt principles) and an analytical approach. Gestalt perception finds its rationale in the evidence that perception of any given object or experience exhibits intrinsic qualities that cannot be completely reduced to visual, auditory, tactile, olfactory, or gustatory components. Thus, perceptions are not constructed in a "bottom-up" fashion from such elements, but are instead globally perceived, in a more "top-down" fashion. Gestalt perception, if cautiously and carefully combined with structured (techno)logical tools, would permit one to defoliate the often too-many-branches built diagnostic trees, and help physicians to better develop their competency. On the other hand, the practice of evidence-based medicine lies in the integration of individual clinical expertise and judgment with the best available external clinical evidence from systematic research. This article is aimed at providing some general concepts about Gestalt perception, and to discuss some aspects of clinical practice potentially influenced by this approach.
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Affiliation(s)
- Gianfranco Cervellin
- Emergency Department, Academic Hospital of Parma, Via Gramsci, 14, 43126, Parma, Italy,
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Price HL, Dahl LC. Order and Strength Matter for Evaluation of Alibi and Eyewitness Evidence. APPLIED COGNITIVE PSYCHOLOGY 2013. [DOI: 10.1002/acp.2983] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Leora C. Dahl
- Department of Psychology; Okanagan College; Kelowna Canada
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12
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Braude HD. Human all too human reasoning: comparing clinical and phenomenological intuition. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2013; 38:173-89. [PMID: 23339120 DOI: 10.1093/jmp/jhs057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This paper compares clinical intuition and phenomenological intuition. I begin with a brief analysis of Husserl's conception of intuition. Second, I review the attitude toward clinical intuition by physicians and philosophers. Third, I discuss the Aristotelian conception of intellectual intuition or nous and its relation to phronesis. Phronesis provides a philosophical ground for clinical intuition by linking medicine as both a techné and praxis. Considering medicine as a techné, Pellegrino and Thomasma exclude clinical intuitions from their philosophy of medicine. However, in modeling clinical reasoning on phronesis, they link Aristotelian nous with clinical reasoning. While supporting the application of phronesis to clinical reasoning, I consider Pellegrino and Thomasma's model deficient for eliminating intuition as an inalienable element of clinical reasoning. Rather, clinical intuitions are necessary in linking medicine as both art and practice. This becomes more obvious through the phenomenological analysis of clinical intuitions. Clinical reasoning and phenomenological intuitions are similar in joining the perceptual and intellectual aspects of human judgment. Furthermore, clinical intuitions can be extended to become phenomenological intuitions through phenomenological reflection. Clinical intuitions may be examined phenomenologically for their originary foundations. In this way, medicine acts as a phenomenological clue. Phenomenology provides a method to restore the Hippocratic synthesis of empirical observation and wholism associated with clinical intuitions.
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Miller CS, Hamm LL. Skin-Deep Diagnosis: Affective Bias and Zebra Retreat Complicating the Diagnosis of Systemic Sclerosis. Am J Med Sci 2013; 345:53-6. [DOI: 10.1097/maj.0b013e3182684aab] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Clinical reasoning has been defined as a form of cognition applied to evaluating and managing a patient's medical problem. As a kind of cognition, a product of the human psyche, it is logical to expect that clinical reasoning should be best understood through methods derived from psychology, neuropsychology and the cognitive sciences. However, the application of scientific methods to evaluating clinical reasoning is unable to analyse clinical reasoning in terms of first-person experience and consciousness. By reducing clinical reasoning to its cognitive components the cognitivist approach tends to ignore the larger context in which clinical reasoning occurs. By reducing its conception of clinical reasoning to its cognitive components, the neuropsychological approach fails to acknowledge clinical reasoning as a form of intentionality, a gestalt, grounded in human perception. A full epistemology of clinical reasoning requires a phenomenological analysis that can make sense of the relation between pre-reflective consciousness and explicit forms of knowing. In this paper I conciliate cognition and consciousness in medicine through analysing the phenomenology of perception in clinical reasoning. I compare the application of phenomenology to clinical reasoning with the attempt to model clinical reasoning on Aristotelian practical wisdom or phronesis. Finally, I analyse empathy as a type of perception critical for effective clinical interaction and exemplary for reflecting on perception as the intersubjective foundation of clinical reasoning.
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Affiliation(s)
- Hillel D Braude
- Faculty of Religious Studies, McGill University, Montreal, QC, Canada.
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Dowding D. Commentary on Banning M (2008) A review of clinical decision making: models and current research. Journal of Clinical Nursing 17, 187-195. J Clin Nurs 2009; 18:309-11. [PMID: 19120761 DOI: 10.1111/j.1365-2702.2008.02471.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dawn Dowding
- Department of Health Sciences and Hull York Medical School, The University of York, York, UK.
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Braude HD. Clinical intuition versus statistics: different modes of tacit knowledge in clinical epidemiology and evidence-based medicine. THEORETICAL MEDICINE AND BIOETHICS 2009; 30:181-198. [PMID: 19548116 DOI: 10.1007/s11017-009-9106-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine's epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi's theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine.
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Affiliation(s)
- Hillel D Braude
- Biomedical Ethics Unit, McGill University, 3647 Peel Street, Montreal, QC H3A1X1, Canada.
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Edmondson R, Pearce J, Woerner MH. Wisdom in clinical reasoning and medical practice. THEORETICAL MEDICINE AND BIOETHICS 2009; 30:231-247. [PMID: 19551491 DOI: 10.1007/s11017-009-9108-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Exploring informal components of clinical reasoning, we argue that they need to be understood via the analysis of professional wisdom. Wise decisions are needed where action or insight is vital, but neither everyday nor expert knowledge provides solutions. Wisdom combines experiential, intellectual, ethical, emotional and practical capacities; we contend that it is also more strongly social than is usually appreciated. But many accounts of reasoning specifically rule out such features as irrational. Seeking to illuminate how wisdom operates, we therefore build on Aristotle's work on informal reasoning. His account of rhetorical communication shows how non-formal components can play active parts in reasoning, retaining, or even enhancing its reasonableness. We extend this account, applying it to forms of healthcare-related reasoning which are characterised by the need for wise decision-making. We then go on to explore some of what clinical wise reasoning may mean, concluding with a case taken from psychotherapeutic practice.
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Affiliation(s)
- Ricca Edmondson
- School of Political Science and Sociology, National University of Ireland, Galway, Galway, Ireland.
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Ericsson KA. An expert-performance perspective of research on medical expertise: the study of clinical performance. MEDICAL EDUCATION 2007; 41:1124-30. [PMID: 18045365 DOI: 10.1111/j.1365-2923.2007.02946.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
CONTEXT Three decades ago Elstein et al. published their classic book on medical expertise, in which they described their failure to identify superior performance by peer-nominated diagnosticians using high- and low-fidelity simulations of the everyday practice of doctors. OBJECTIVE This paper reviews the results of subsequent research, with a particular emphasis on the progress toward Elstein et al.'s goal of capturing the essence of superior clinical performance in standardised settings in order to improve clinical practice. RESULTS Research following publication of Elstein et al.'s book was influenced by laboratory research in cognitive psychology, which resulted in a redirection of its original focus on capturing clinical performance in practice to studies of changes in cognitive processes as functions of extended clinical experience. There is currently renewed interest in linking laboratory research with studies of the acquisition of superior (expert) performance in the clinic. CONCLUSIONS Research on medical expertise and simulation training in technical procedures and diagnosis provide exciting opportunities for establishing translational research on the acquisition of superior (expert) performance in the clinic by capturing it with representative tasks in the laboratory, reproducing it for experimental analysis, and developing training activities, such as deliberate practice, that can induce measurable improvements in performance in the clinic.
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Affiliation(s)
- K Anders Ericsson
- Department of Psychology, Florida State University, Tallahassee, Florida 32306-4301, USA.
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Abstract
This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.
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Affiliation(s)
- John Paley
- Department of Nursing and Midwifery, University of Stirling, Stirling, UK.
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O'Neill ES, Dluhy NM, Chin E. Modelling novice clinical reasoning for a computerized decision support system. J Adv Nurs 2005; 49:68-77. [DOI: 10.1111/j.1365-2648.2004.03265.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tamayo-Sarver JH, Dawson NV, Cydulka RK, Wigton RS, Baker DW. Variability in emergency physician decisionmaking about prescribing opioid analgesics. Ann Emerg Med 2004; 43:483-93. [PMID: 15039692 DOI: 10.1016/j.annemergmed.2003.10.043] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions. METHODS We developed items thought to influence the decision to prescribe an opioid analgesic through a review of the literature, expert consultation, and interviews with practicing emergency physicians. We developed a baseline vignette and items expected to influence the decision for each of the 3 conditions: migraine, back pain, and ankle fracture. We surveyed 650 physicians randomly selected from the American College of Emergency Physicians. The influence of individual items was explored through a univariate analysis of the response distribution. Patterns were assessed by analytically creating scales. RESULTS We received responses from 398 (63%) of the 634 eligible physicians. Physicians' likelihoods of prescribing an opioid showed marked variability, with at least 10% of physicians saying they were unlikely and 10% of physicians saying they were likely to prescribe for each condition. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were also highly variable, with at least 10% of physicians saying they would be negatively influenced by this request and at least 10% saying they would be positively influenced by it. CONCLUSION Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.
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McCarthy MC. Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments. Res Nurs Health 2003; 26:203-12. [PMID: 12754728 DOI: 10.1002/nur.10081] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In an article on a previous study involving hospitalized older adults (McCarthy, 2003), it was argued that the theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion. Further, the theory illuminates how nurses' perspectives toward health in aging affect the ways they regard and ultimately deal with older people in this particular clinical situation. The purpose of the current study was to challenge and refine the theory by exploring the influence of different care environments on clinical reasoning related to acute confusion. Following a period of participant observation, a purposive sample of 30 nurses, 10 each from a teaching hospital, a long-term facility, and a home care agency, participated in semistructured interviews. Dimensional analysis provided the methodological framework for data collection and interpretation. The results reinforce prior findings that the ability of nurses to recognize acute confusion and to distinguish it from dementia can be attributed to their personal philosophies about aging. Care environment was identified as a factor that influenced clinical reasoning in limited ways under certain conditions and within certain contexts.
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Affiliation(s)
- Marianne C McCarthy
- Arizona State University, College of Nursing, Tempe, Arizona 85287-2602, USA
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McCarthy M. Situated clinical reasoning: distinguishing acute confusion from dementia in hospitalized older adults. Res Nurs Health 2003; 26:90-101. [PMID: 12652606 DOI: 10.1002/nur.10079] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study a dimensional analysis approach was used to explore the clinical reasoning of nurses who care for hospitalized older adults to identify factors that might explain their failure to detect acute confusion and to distinguish it from dementia in this patient population. Data analysis yielded a grounded theory of situated clinical reasoning, which proposes that the ability of nurses to identify acute confusion varies widely. This variation can be attributed to the differences in nurses' philosophical perspectives on aging. According to this theory, three distinct perspectives are unwittingly embraced by nurses who care for older patients. These perspectives influence how nurses characterize aging and the aged and condition the ways in which they judge and ultimately deal with older adults in clinical situations.
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Affiliation(s)
- Marianne McCarthy
- Arizona State University, College of Nursing, Main Campus, P.O. Box 872602, Tempe, AZ 85287-2602, USA
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Abstract
AIM Critical care cardiovascular (CCCV) nursing diagnostic expertise was the focus of this research. The purpose of the study was to compare diagnostic cue utilization between expert and novice CCCV nurses. BACKGROUND Knowledge related to objective measures of clinical nursing diagnostic expertise would enhance effective and efficient recognition, utilization, and reward of clinical expertise. METHODS Five CCCV written simulations served as instruments in the study. Diagnostic content areas included left ventricular dysfunction, cardiac tamponade, sepsis, right ventricular failure, and hypovolemia related to internal abdominal haemorrhage. The sample was composed of 23 expert and 23 novice nurses. After reading each simulation, subjects were asked to verbally recall the simulation, give an impression of the predominant problem or diagnosis, and give a diagnostic explanation. Verbal recalls were audio-taped for protocol analysis. Diagnostic accuracy and cue utilization were determined through comparisons of subjects' recalled diagnoses and cues with results from an expert panel review consensus. The major variable was the mean recalled proportion of highly relevant cues to total cues (HRC/TC) on accurately diagnosed simulations. Chi-square analysis revealed that diagnostic accuracy was greater with experts than with novices. Differences between and among simulations, expertise, accuracy and the mean proportion of highly relevant cues to total cues were examined with a 4 x 2 x 2 factorial analysis of variance. RESULTS When considering all accurately diagnosed simulations, experts had a higher HRC/TC than novices. The major limitations were the use of low fidelity written simulations and virgin verbal protocol methods. CONCLUSION The findings generally support the idea that the development of diagnostic expertise is associated with the ability to focus on highly relevant cues.
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Affiliation(s)
- Rosalyn R Reischman
- College of Nursing, University of Florida, Jacksonville, Florida 32204, USA.
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