Exam Room Computers and Patient-Clinician Communication: A Wicked Problem

The present study is a primarily qualitative case study examining the patient-clinician relationship. Clinicians practicing within an oncology practice with a reputation for patient-centered care responded to questions regarding how the introduction of an electronic medical record (EMR) and an exam room computer had affected their day-to-day clinical practice. Framed as a wicked problem (a problem that could not be solved using a linear methodology), I believed clues to understanding a method for incorporating use of an exam room computer into a clinical visit while maintaining empathic communication with the patient could be found by exploring the experience of clinicians who had faced the dilemma. Only three of the nine clinicians interviewed reported routinely using the computer to document the visit while the patient was in the room. The exam room computer was perceived by the clinicians as a third interaction in addition to the patient-clinician relationship and had changed the dynamics of the clinical visit. Identified disadvantages to using an exam room computer included physical environmental factors and relational problems created by system failures or slowness where the clinician felt obligated to explain the unwelcome interruptions of the clinical visit by acknowledging to the patient the interference of the damn computer. Environmental factors interfered with empathic communication by limiting nonverbal communication, particularly eye contact. Similarly, relational factors made empathic communication more difficult by interrupting the flow of conversation or pulling the clinician\u27s attention away from the patient. The clinicians who used the exam room computer in the presence of the patient were unable to verbalize a specific technique they had discovered to unable them to maintain an empathic connection with their patients. However, in explaining how they had adapted their practice after the introduction of the exam room computer they demonstrated a strong commitment to their patients through mindfulness and reflexivity. The empathic connection between these clinicians and their patients was maintained through an awareness of how their words and behavior might be perceived by the patient, and a conscious effort to keep the patient at the center of the interaction despite distractions introduced by the computer

Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students

This volume describes and explains the educational method of Case-Based Clinical Reasoning (CBCR) used successfully in medical schools to prepare students to think like doctors before they enter the clinical arena and become engaged in patient care. Although this approach poses the paradoxical problem of a lack of clinical experience that is so essential for building proficiency in clinical reasoning, CBCR is built on the premise that solving clinical problems involves the ability to reason about disease processes. This requires knowledge of anatomy and the working and pathology of organ systems, as well as the ability to regard patient problems as patterns and compare them with instances of illness scripts of patients the clinician has seen in the past and stored in memory. CBCR stimulates the development of early, rudimentary illness scripts through elaboration and systematic discussion of the courses of action from the initial presentation of the patient to the final steps of clinical management. The book combines general backgrounds of clinical reasoning education and assessment with a detailed elaboration of the CBCR method for application in any medical curriculum, either as a mandatory or as an elective course. It consists of three parts: a general introduction to clinical reasoning education, application of the CBCR method, and cases that can used by educators to try out this method

Perspective Chapter: Evidence-Based Medicine - A New Approach for Medical Education and Practice

The new concept is gaining worldwide recognition and acceptance in medical education and practice. Evidence-based medicine (EBM) is the term used to describe this novel approach to the teaching and practice of medicine. The purpose of this chapter is to give you a brief overview of the components of EBM, EBM principles, the steps of EBM practice, and the skills required for EBM that can shape your approach toward EBM. A review of the English-language literature was conducted in PubMed, Google Scholar, and Google to obtain EBM definitions, the components of EBM, EBM principles, the steps of EBM practice, and the skills required for EBM. EBM is the integration of the best available research evidence with clinical expertise and patient values. It consists of three basic components: the best available evidence, clinical expertise, and patient values. The integration of these three components can be effectively achieved by completing the five steps of the EBM practice. The five-step process of EBM is asking, acquiring, appraising, applying the evidence in clinical decisions, and assessing the outcome

A systems approach to improving patient safety through medical device purchasing

The purchase of medical devices involves engaging various stakeholders as well as balancing clinical, technical and financial requirements. Failure to consider these requirements can lead to wider consequences in the delivery of care. This study first builds a general knowledge base of current purchasing practice in a sample of NHS Trusts, which confirms the direction and guidance given by policy documents and literature as to the extent of the challenges faced by purchasing stakeholders. This then leads to an analysis to identify inefficiencies in the purchasing process, and how such practice can lead to risks in the delivery of care. These risks range from injury to individuals, impacts to the healthcare delivery service, and financial and litigation risks. Finally, a framework that highlights these potential risks in the life-cycle of medical devices in hospitals is presented. Key policy guidance has encouraged both researchers and implementers of healthcare services to approach patient safety from a systems perspective, acknowledging that medical device errors are not only directly related to device design, but to the design of the healthcare delivery service system in which the device operates. Little evidence exists of successfully applying systems approaches specifically to medical device purchasing practice. Medical device purchasing, because of its implications to patient safety on the one hand, and the uniqueness of the healthcare context, requires a unique approach. By demonstrating the influence of purchasing practice to service delivery and patient care, the thesis made is that taking a holistic systems approach is one method to improve device purchasing practice, and hence influence better care.This work was supported by the UK Engineering and Physical Sciences Research Council [EP/E001777/1

Use, Impact, Weaknesses, and Advanced Features of Search Functions for Clinical Use in Electronic Health Records: A Scoping Review

Objective: Although vast amounts of patient information are captured in electronic health records (EHRs), effective clinical use of this information is challenging due to inadequate and inefficient access to it at the point of care. The purpose of this study was to conduct a scoping review of the literature on the use of EHR search functions within a single patient's record in clinical settings to characterize the current state of research on the topic and identify areas for future study. Methods: We conducted a literature search of four databases to identify articles on within-EHR search functions or the use of EHR search function in the context of clinical tasks. After reviewing titles and abstracts and performing a full-text review of selected articles, we included 17 articles in the analysis. We qualitatively identified themes in those articles and synthesized the literature for each theme. Results: Based on the 17 articles analyzed, we delineated four themes: (1) how clinicians use search functions, (2) impact of search functions on clinical workflow, (3) weaknesses of current search functions, and (4) advanced search features. Our review found that search functions generally facilitate patient information retrieval by clinicians and are positively received by users. However, existing search functions have weaknesses, such as yielding false negatives and false positives, which can decrease trust in the results, and requiring a high cognitive load to perform an inclusive search of a patient's record. Conclusion: Despite the widespread adoption of EHRs, only a limited number of articles describe the use of EHR search functions in a clinical setting, despite evidence that they benefit clinician workflow and productivity. Some of the weaknesses of current search functions may be addressed by enhancing EHR search functions with collaborative filtering

Evidence-Based Practice for the Athletic Training Profession

As evidence-based practice (EBP) becomes a necessity in athletic training, it is essential to recognize current barriers and modes of accessibility to information for enhancement of clinical decision-making. Furthermore, the effectiveness of educational interventions (EI) to enhance knowledge of EBP concepts must be investigated. The aim of Project I was to assess attitudes and beliefs, perceived barriers, and accessibility to resources of EBP among athletic trainers (AT). Project II was designed to investigate the effect of an EI on enhancing AT\u27s knowledge of EBP concepts. Project III explored ATs\u27 experiences of the EI and whether it elicited changes within their educational or clinical practices. The Evidence-Based Concepts Assessment (EBCA) was utilized in Project I to survey 1,209 athletic training educators, clinicians, and post-professional students. Overall, participants agree (3.27) EBP has various benefits to clinical practice and disagree (2.23) that there are negative perceptions associated with EBP. Clinical prediction rules (22.1%) and Cochrane databases (22.8%) were the two resources with the least direct access. Time (76.6%) and availability of EBP mentors (69.6%) were the two most prevalent barriers towards implementation of EBP. Project II consisted of the development of 10 online modules focusing on various EBP concepts; these online modules were assessed through a randomized controlled trial design among 164 athletic training educators, clinicians, and students. Composite scores on the Evidence-Based Practice Knowledge Assessment prior to implementation phase did not differ between the control and experimental group (MCPre=30.12±5.73, M EPre=30.65±5.93); however, the experimental group (M EPost=36.35±8.58) obtained significantly higher scores (P=0.013) on the post-assessment compared to the control group (MCPost=30.99±6.33). No differences were identified between time instances within the control group ( P=0.080); however the experimental group obtained significantly higher scores on the post-assessment than the pre-assessment (P\u3c0.001). The 25 ATs (12 educators, 13 clinicians) interviewed six months following the implementation of the online modules identified knowledge gain and enhanced importance of EBP as beneficial outcomes of the modules. Educators described a positive impact on teaching as well as the ability to instill value and practice of EBP among students. Clinicians reported an enhanced ability to implement EBP following the modules, but that the EI did not directly impact behavioral changes within daily clinical practice. Strategies to incorporate EBP throughout the athletic training profession were also identified

Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students

assessment of clinical reasoning; diagnostic bias; diagnostic errors; dual process theory; scripts; medical problem-solving; peer teaching; problem-based learning; semantic qualifier

Publishing Addiction Science

"Publishing Addiction Science is a comprehensive guide for addiction scientists facing the complex process of contributing to scholarly journals. Written by an international group of addiction journal editors and their colleagues, it discusses how to write research articles and systematic reviews, choose a journal, respond to reviewers’ reports, become a reviewer, and resolve the often difficult authorship, ethical and citation issues that arise in addiction science publishing. As a “Guide for the Perplexed,” Publishing Addiction Science helps novice as well as experienced researchers to deal with these challenges. It is suitable for university courses and forms the basis of the training workshops offered by the International Society of Addiction Journal Editors (ISAJE). Co-sponsored by ISAJE and the scientific journal Addiction, the third edition of Publishing Addiction Science gives special attention to the challenges faced by researchers from developing and non-English-speaking countries and features new chapters on guidance for clinician-scientists and the growth of infrastructure and career opportunities in addiction science.

Designing Visual Markers for Continuous Artificial Intelligence Support

Colonoscopy, the visual inspection of the large bowel using an endoscope, offers protection against colorectal cancer by allowing for the detection and removal of pre-cancerous polyps. The literature on polyp detection shows widely varying miss rates among clinicians, with averages ranging around 22%--27%. While recent work has considered the use of AI support systems for polyp detection, how to visualise and integrate these systems into clinical practice is an open question. In this work, we explore the design of visual markers as used in an AI support system for colonoscopy. Supported by the gastroenterologists in our team, we designed seven unique visual markers and rendered them on real-life patient video footage. Through an online survey targeting relevant clinical staff (N = 36), we evaluated these designs and obtained initial insights and understanding into the way in which clinical staff envision AI to integrate in their daily work-environment. Our results provide concrete recommendations for the future deployment of AI support systems in continuous, adaptive scenarios