Professional approaches in clinical judgements among senior and junior doctors: implications for medical education

<p>Abstract</p> <p>Background</p> <p>Clinical experience has traditionally been highly valued in medical education and clinical healthcare. On account of its multi-faceted nature, clinical experience is mostly difficult to articulate, and is mainly expressed in clinical situations as professional approaches. Due to retirement, hospitals in Scandinavia will soon face a substantial decrease in the number of senior specialist doctors, and it has been discussed whether healthcare will suffer an immense loss of experienced-based knowledge when this senior group leaves the organization. Both senior specialists and junior colleagues are often involved in clinical education, but the way in which these two groups vary in professional approaches and contributions to clinical education has not been so well described. Cognitive psychology has contributed to the understanding of how experience may influence professional approaches, but such studies have not included the effect of differences in position and responsibilities that junior and senior doctors hold in clinical healthcare. In the light of the discussion above, it is essential to describe the professional approaches of senior doctors in relation to those of their junior colleagues. This study therefore aims to describe and compare the professional approaches of junior and senior doctors when making clinical judgements.</p> <p>Methods</p> <p>Critical incident technique was used in interviews with nine senior doctors and nine junior doctors in internal medicine. The interviews were subjected to qualitative content analysis.</p> <p>Result</p> <p>Senior and junior doctors expressed a variety of professional approaches in clinical judgement as follows: use of theoretical knowledge, use of prior experience of cases and courses of events, use of ethical and moral values, meeting and communicating with the patient, focusing on available information, relying on their own ability, getting support and guidance from others and being directed by the organization.</p> <p>Conclusion</p> <p>The most prominent varieties of professional approaches were seen in use of knowledge and work-related experience. Senior doctors know how the organization has worked in the past and have acquired techniques with respect to long-term decisions and their consequences. Junior doctors, on the other hand, have developed techniques and expertise for making decisions based on a restricted amount of information, in relation to patients' wellbeing as well as organizational opportunities and constraints. This study contributes to medical education by elucidating the variation in professional approaches among junior and senior doctors, which can be used as a basis for discussion about clinical judgement, in both pre-clinical and clinical education. Further research is required to explain how these professional approaches are expressed and used in clinical education.</p

Psychophysiological Correlates of Sexually and Non-Sexually Motivated Attention to Film Clips in a Workload Task

Some authors have speculated that the cognitive component (P3) of the Event-Related Potential (ERP) can function as a psychophysiological measure of sexual interest. The aim of this study was to determine if the P3 ERP component in a workload task can be used as a specific and objective measure of sexual motivation by comparing the neurophysiologic response to stimuli of motivational relevance with different levels of valence and arousal. A total of 30 healthy volunteers watched different films clips with erotic, horror, social-positive and social-negative content, while answering an auditory oddball paradigm. Erotic film clips resulted in larger interference when compared to both the social-positive and auditory alone conditions. Horror film clips resulted in the highest levels of interference with smaller P3 amplitudes than erotic and also than social-positive, social-negative and auditory alone condition. No gender differences were found. Both horror and erotic film clips significantly decreased heart rate (HR) when compared to both social-positive and social-negative films. The erotic film clips significantly increased the skin conductance level (SCL) compared to the social-negative films. The horror film clips significantly increased the SCL compared to both social-positive and social-negative films. Both the highly arousing erotic and non-erotic (horror) movies produced the largest decrease in the P3 amplitude, a decrease in the HR and an increase in the SCL. These data support the notion that this workload task is very sensitive to the attentional resources allocated to the film clip, although they do not act as a specific index of sexual interest. Therefore, the use of this methodology seems to be of questionable utility as a specific measure of sexual interest or as an objective measure of the severity of Hypoactive Sexual Desire Disorder

A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology

<p>Abstract</p> <p>Background</p> <p>Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge.</p> <p>Methods/design</p> <p>The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions.</p> <p>Discussion</p> <p>The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.</p

DNA methylation, the early-life social environment and behavioral disorders

One of the outstanding questions in behavioral disorders is untangling the complex relationship between nurture and nature. Although epidemiological data provide evidence that there is an interaction between genetics (nature) and the social and physical environments (nurture) in a spectrum of behavioral disorders, the main open question remains the mechanism. Emerging data support the hypothesis that DNA methylation, a covalent modification of the DNA molecule that is a component of its chemical structure, serves as an interface between the dynamic environment and the fixed genome. We propose that modulation of DNA methylation in response to environmental cues early in life serves as a mechanism of life-long genome adaptation. Under certain contexts, this adaptation can turn maladaptive resulting in behavioral disorders. This hypothesis has important implications on understanding, predicting, preventing, and treating behavioral disorders including autism that will be discussed

A review on experimental and clinical genetic associations studies on fear conditioning, extinction and cognitive-behavioral treatment

Fear conditioning and extinction represent basic forms of associative learning with considerable clinical relevance and have been implicated in the pathogenesis of anxiety disorders. There is considerable inter-individual variation in the ability to acquire and extinguish conditioned fear reactions and the study of genetic variants has recently become a focus of research. In this review, we give an overview of the existing genetic association studies on human fear conditioning and extinction in healthy individuals and of related studies on cognitive-behavioral treatment (CBT) and exposure, as well as pathology development after trauma. Variation in the serotonin transporter (5HTT) and the catechol-o-methyltransferase (COMT) genes has consistently been associated with effects in pre-clinical and clinical studies. Interesting new findings, which however require further replication, have been reported for genetic variation in the dopamine transporter (DAT1) and the pituitary adenylate cyclase 1 receptor (ADCYAP1R1) genes, whereas the current picture is inconsistent for variation in the brain-derived neurotrophic factor (BDNF) gene. We end with a discussion of the findings and their limitations, as well as future directions that we hope will aid the field to develop further

Protocol requirements and diagnostic value of PET/MR imaging for liver metastasis detection

PURPOSE: To compare the accuracy of PET/MR imaging with that of FDG PET/CT and to determine the MR sequences necessary for the detection of liver metastasis using a trimodality PET/CT/MR set-up. METHODS: Included in this single-centre IRB-approved study were 55 patients (22 women, age 61 ± 11 years) with suspected liver metastases from gastrointestinal cancer. Imaging using a trimodality PET/CT/MR set-up (time-of-flight PET/CT and 3-T whole-body MR imager) comprised PET, low-dose CT, contrast-enhanced (CE) CT of the abdomen, and MR with T1-W/T2-W, diffusion-weighted (DWI), and dynamic CE imaging. Two readers evaluated the following image sets for liver metastasis: PET/CT (set A), PET/CECT (B), PET/MR including T1-W/T2-W (C), T1-W/T2-W with either DWI (D) or CE imaging (E), and a combination (F). The accuracy of each image set was determined by receiver-operating characteristic analysis using image set B as the standard of reference. RESULTS: Of 120 liver lesions in 21/55 patients (38 %), 79 (66 %) were considered malignant, and 63/79 (80 %) showed abnormal FDG uptake. Accuracies were 0.937 (95 % CI 89.5 - 97.9 %) for image set A, 1.00 (95 % CI 99.9 - 100.0 %) for set C, 0.998 (95 % CI 99.4 - 100.0 %) for set D, 0.997 (95 % CI 99.3 - 100.0 %) for set E, and 0.995 (95 % CI 99.0 - 100.0 %) for set F. Differences were significant for image sets D - F (P < 0.05) when including lesions without abnormal FDG uptake. As shown by follow-up imaging after 50 - 177 days, the use of image sets D and both sets E and F led to the detection of metastases in one and three patients, respectively, and further metastases in the contralateral lobe in two patients negative on PET/CECT (P = 0.06). CONCLUSION: PET/MR imaging with T1-W/T2-W sequences results in similar diagnostic accuracy for the detection of liver metastases to PET/CECT. To significantly improve the characterization of liver lesions, we recommend the use of dynamic CE imaging sequences. PET/MR imaging has a diagnostic impact on clinical decision making