Representation, interaction and interpretation. Making sense of the context in clinical reasoning

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.

Unravelling the polyphony in clinical reasoning research in medical education

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.

Medical students' self-reported gender discrimination and sexual harassment over time

BACKGROUND

Gender discrimination (GD) and sexual harassment (SH) occur at all academic institutions worldwide. Medical students report high prevalence of GD and SH, which may negatively affect their education and health. There are indications that policies and reforms on reducing GD/SH are insufficient. Swedish medical students' experiences of GD/SH are monitored by course-evaluations and bi-annual student union evaluations; however, the response rate is usually low. The aim of this study was to compare the exposure to and context of self-reported GD/SH over an 11-year period amongst medical students at a Swedish university.

METHODS

In 2002, a questionnaire (n = 622) was mailed to medical students' home addresses. It was repeated in 2013 and then distributed during mandatory lectures (n = 856). The questions used a behavioristic approach and asked about specific GH/SH experiences. Participation was voluntary and anonymous. The changes in prevalence over time were calculated by sampling weights in order to obtain comparable estimates, representative of both cohorts.

RESULTS

The response frequency was 55% (62% women) in 2002 and 81% (59% women) in 2013. The prevalence of GD tended to decrease for male and clinical students in comparison to female and pre-clinical peers. However, the prevalence of SH increased for female compared to male students. The ratio of SH for female pre-clinical students doubled in many instances; most often, the mistreatment occurred in the clinic. Medical doctors were indicated as perpetrators up to five times more often by all students in 2013.

CONCLUSION

Our results show a disproportional change in exposure to GD/SH between female and male medical students, resulting in a widening of the gender gap regarding prevalence of GD and SH between 2002 and 2013. In particular, personal experiences of SH increased for both sexes. It is proof that institutional efforts to fight mistreatment might be ineffective.

Grounding judgement in context: A conceptual learning model of clinical reasoning

CONTEXT

Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment.

METHOD

We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships.

RESULTS

Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements.

CONCLUSIONS

Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.

Ultrasound Curricula of Student Education in Europe: Summary of the Experience

Background Despite the increasing role of ultrasound, structured ultrasound teaching is only slowly being integrated into the curricula of medical schools and universities all over Europe.

Aim To survey the current situation at European universities regarding the integration of ultrasound in student medical education and to report on models of student ultrasound training from selected European universities.

Methods A questionnaire survey focusing on the implementation of curricular ultrasound education was sent out to the 28 presidents of the national ultrasound societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), who were asked to distribute the questionnaires to the medical universities of their countries.

Results Overall, 53 questionnaires were returned from 46 universities in 17 European countries. In most of the universities (40/46 universities, 87%), the theoretical background of ultrasound is taught. However, in only a minority of universities is ultrasound integrated in anatomy courses (8/46 universities, 17%) or basic science courses (16/46 universities, 35%). Practical skills in ultrasound are taught in 56% of the universities (26/46 universities) and tested in a practical exam in seven of the responding universities (15%). The number of hours in which ultrasound was taught ranged from one to 58 (mean, seven). The respondents reported that lack of time and limited faculty funding were major hurdles.

Conclusion According to our survey, only a minority of European universities has integrated ultrasound into the preclinical curriculum thus far. Future EFSUMB initiatives will continue to promote the introduction of ultrasound as an integrative part of the core curriculum of student medical education, and the preparation of proper teaching material.

Twelve tips for enhancing student engagement

Student engagement refers to a broad range of activities where students participate in management, education, research, and community activities within their institutions. It is a mutually beneficial collaborative approach between students and their institutions. This article provides practical advice for the implementation or further development of student engagement at medical, dental, and veterinary schools. The tips provided are based on the experiences of a group of universities recently recognized for best practice in student engagement, and are supported by evidence from the literature. The tips cover overarching themes which include the creation of an institutional culture and formal framework for student engagement, and maximize communication routes between students with peers and faculty. Tips are for specific areas of active student engagement, covering curriculum design and development, peer teaching, governance processes, research activities, peer support programs, and interaction with the local community.

The echogenicity of the intima-media complex in the common carotid artery is related to insulin resistance measured by the hyperinsulinemic clamp in elderly men

The echogenicity of the intima-media complex (IM-GSM) has recently been shown to be related to the echogenicity in carotid artery plaque and to predict cardiovascular (CV) mortality. The present study aims to evaluate the relationship between metabolic CV risk factors, with special emphasis on insulin resistance, and IM-GSM in the carotid artery. Carotid artery ultrasound with grey-scale median analysis of the intima-media complex, IM-GSM, was performed in a population sample of 480 men aged 75 years. In these subjects, a euglycemic hyperinsulinemic clamp to investigate insulin resistance was performed together with measurements of conventional CV risk factors at the age of 70. The metabolic syndrome (MetS) was defined by the NCEP/ATPIII-criteria. In univariate analysis, IM-GSM in the common carotid artery was inversely correlated with the intima-media thickness (IMT), body mass index (BMI), waist/hip ratio, fasting glucose, serum triglycerides, low HDL cholesterol and insulin resistance at the clamp (r = -0·24, P<0·001). In multiple regression analysis, only insulin resistance at the clamp and BMI were independently related to IM-GSM. Subjects with the MetS (22%) showed a reduced IM-GSM when compared to those without (64 ± 20 SD versus 68 ± 19, P<0·05). Because the echogenicity of the intima-media complex in the carotid artery is related to obesity and insulin resistance at clamp independently of IMT, this new vascular characteristic would serve as a marker of vascular alterations induced by insulin resistance and the MetS and has the advantage to be obtainable in almost all subjects.

An echolucent carotid artery intima-media complex is a new and independent predictor of mortality in an elderly male cohort

BACKGROUND

The echogenicity of atherosclerotic plaques is a measure of their lipid content and predicts cardiovascular disease. We hypothesized that the echogenicity of the non-plaque-affected arterial wall may be prognostically important as well, and more easily used as not all subjects carry plaques. We investigated the prognostic value of intima-media (IM) echogenicity (measured as the grey scale median [GSM]) for mortality compared with intima-media thickness (IMT) in a population-based sample of elderly men.

METHODS

A cohort from a community-based sample of 491 men was investigated with carotid artery ultrasound at age 75. IMT and GSM for IM and plaques were measured in the far wall of the common carotid artery being apparently free of plaque. Cox proportional hazard analysis models were used to investigate linear and non-linear relations of IM-GSM to mortality, adjusted for IMT, body mass index, cholesterol, HDL-cholesterol, triglycerides, systolic blood pressure, antihypertensive treatment, CRP, diabetes, current smoking, pack years of smoking, and previous cardiovascular disease.

RESULTS

Seventy-seven subjects died during a median follow-up time of 5.1 years. Participants were divided in tertiles by IM-GSM. In unadjusted analysis, IM-GSM predicted mortality in a U-shaped manner. In Cox proportional hazard analyses, an echolucent IM-GSM was a predictor of all-cause mortality (HR: 3.23; CI: 1.60-6.54; p<0.05) and CVD mortality (n=30, HR: 8.29; CI: 2.03-33.92; p<0.05) independently of IMT and established risk factors. These associations were still significant following adjustment for plaque occurrence and plaque echogenicity.

CONCLUSION

An echolucent intima-media complex is a predictor of all-cause and CVD mortality in elderly men independently of plaque occurrence, plaque GSM, IMT and established risk factors, suggesting the echogenicity of the apparently plaque-free intima-media complex provides novel prognostic information regarding mortality after age 75.

Both cyclooxygenase- and cytokine-mediated inflammation are associated with carotid intima–media thickness

BACKGROUND

Common carotid artery intima-media thickness (CCA-IMT) is a valid index of atherosclerosis, which is viewed as an inflammatory disease. It is unknown if various modes of inflammation (cyclooxygenase [COX]-mediated, cytokine-mediated), oxidative stress and anti-oxidants are independently related to CCA-IMT.

METHODS AND RESULTS

We investigated cross-sectional relations between CCA-IMT measured by B-mode ultrasound and COX-mediated inflammation (as measured by 15-keto-dihydro-prostaglandin F(2alpha) [PGF(2alpha)], cytokine-mediated inflammation (interleukin-6 [IL-6], high sensitivity C-reactive protein [hsCRP] and serum amyloid A protein [SAA]), oxidative stress (8-iso-PGF(2alpha), an F(2)-isoprostane; a non-enzymatic, free radical-induced product of arachidonic acid), and tocopherols (anti-oxidants) in a small subset of a population-based sample of elderly men (n=234) stating no use of anti-inflammatory medications. In a backward-stepwise regression analysis of correlates of CCA-IMT (with PGF(2alpha), hsCRP, IL-6, SAA, F(2)-isoprostanes, tocopherols, diabetes, body mass index (BMI), beta-blocker, statin treatment, smoking, hypertension and cholesterol), PGF(2alpha), CRP, beta-blocker treatment, diabetes and BMI were independently associated with CCA-IMT. There were no associations between F(2)-isoprostanes or tocopherols and CCA-IMT in this study.

CONCLUSION

This study suggests both COX- and cytokine-mediated inflammation to be independently associated with increased CCA-IMT, implying that there might be more than one mode of inflammation involved in atherogenesis.

Apolipoprotein E epsilon4 genotype is independently associated with increased intima-media thickness in a recessive pattern

Polymorphisms in the apolipoprotein E (Apo E) gene have been associated with lipid levels, carotid intima media thickness (CCA-IMT), inflammation and cardiovascular disease (CVD). Earlier findings suggested an association of the Apo E alleles with increased CCA-IMT following a recessive pattern. Whether associations might be independent of C-reactive protein (CRP), lipid levels and other CVD risk factors is not known. We investigated the relationships between Apo E (epsilon2, epsilon3 and epsilon4 alleles) and CCA-IMT, measured by B-mode ultrasound, in dominant and recessive models in a community-based sample of 437 men 75 years of age. In men homozygous for the epsilon4 allele CCA-IMT was significantly increased by 0.13 mm to 0.86 +/- 0.16 mm compared to 0.73 +/- 0.19 mm in non- epsilon4-carriers (P = 0.0012) and 0.73 +/- 0.21 mm in epsilon4 heterozygous (P = 0.0044) in unadjusted recessive models. The association between Apo E epsilon4 genotype and CCA-IMT was independent of Apo E epsilon2 and Apo E epsilon3 alleles, CRP, lipid variables (TG, LDL, HDL) and other CVD risk factors (smoking, hypertension, body mass index, diabetes) (P = 0.018). No relations between Apo E genotype and CCA-IMT were observed in dominant models. No significant associations between the Apo E epsilon2 and epsilon3 alleles and CCA-IMT were found. In this study, men homozygous with the ApoE epsilon4 allele had thicker CCA-IMT, independently of Apo E epsilon2 and epsilon3 alleles, CRP, lipid variables (TG, LDL, HDL) and other CVD risk factors (smoking, hypertension, body mass index, diabetes), suggesting CCA-IMT to be modified by the ApoE epsilon4 genotype in a recessive pattern.

Impaired insulin sensitivity is an independent predictor of common carotid intima-media thickness in a population sample of elderly men

Most previous studies of associations between insulin sensitivity and common carotid artery (CCA) atherosclerosis have been conducted in small samples, have not used direct measurement of insulin sensitivity, and have yielded inconclusive results. We investigated associations of CCA intima-media thickness (IMT) and diameter (CCA-D) measured by B-mode ultrasound and insulin sensitivity measured by the euglycemic hyperinsulinemic clamp test together with risk factors of the insulin resistance syndrome in a community-based sample of 493 elderly men. The clamp glucose disposal rate was an independent predictor of CCA-IMT in multivariate models adjusting for blood pressure, smoking, serum cholesterol, and body mass index (1% decrease in CCA-IMT for a 1 unit increase in glucose disposal rate, P=0.009). Glucose disposal rate was significantly related to CCA-D in univariate (r=-0.11, P=0.02) but not in multivariate models. In conclusion, this study is the first to establish impaired insulin sensitivity, measured by the euglycemic hyperinsulinemic clamp test, as an independent predictor of CCA-IMT in a population-based sample of elderly men.