The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective

Context: The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the ‘acquisition’ of clinical skills. Objectives: This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus’ main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims. Conclusions: Although the Dreyfus model may partially explain the ‘acquisition’ of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain ‘acquisition’ of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully

The monoclonal antibody EPR1614Y against the stem cell biomarker keratin K15 lacks specificity and reacts with other keratins

Keratin 15 (K15), a type I keratin, which pairs with K5 in epidermis, has been used extensively as a biomarker for stem cells. Two commercial antibodies, LHK15, a mouse monoclonal and EPR1614Y, a rabbit monoclonal, have been widely employed to study K15 expression. Here we report differential reactivity of these antibodies on epithelial cells and tissue sections. Although the two antibodies specifically recognised K15 on western blot, they reacted differently on skin sections and cell lines. LHK15 reacted in patches, whereas EPR1614Y reacted homogenously with the basal keratinocytes in skin sections. In cultured cells, LHK15 did not react with K15 deficient NEB-1, KEB-11, MCF-7 and SW13 cells expressing only exogenous K8 and K18 but reacted when these cells were transduced with K15. On the other hand, EPR1614Y reacted with these cells even though they were devoid of K15. Taken together these results suggest that EPR1614Y recognises a conformational epitope on keratin filaments which can be reconstituted by other keratins as well as by K15. In conclusion, this report highlights that all commercially available antibodies may not be equally specific in identifying the K15 positive stem cell

Integrating Teaching Skills and Clinical Content in a Faculty Development Workshop

Incorporating clinical content into medical education faculty development programs has been proposed as a strategy to consolidate faculty continuing medical education time and enhance learning. We developed a faculty development program for ambulatory internal medicine preceptors that integrated primary care genetics with ambulatory precepting. The instructional strategies addressed both areas simultaneously and included facilitated discussions, mini-lectures, trigger tapes, and role plays. To evaluate the program, we conducted a pre-post trial. Skills were measured by retrospective pre-post self-reported ratings and behaviors by self-reported implementation of commitment to change (CTC) statements. Participants' (N = 26) ambulatory precepting and primary care genetics skill ratings improved after the intervention. They listed an average of 2.4 clinical teaching CTC statements and 2.0 clinical practice CTC statements. By 3 months after the workshop, preceptors, as a group, fully implemented 32 (38%), partially implemented 35 (41%), and failed to implement 18 (21%) CTC statements. The most common barrier to clinical teaching change was insufficient skills (8 of 25; 32%) and to clinical practice change was lack of a suitable patient (15 of 25; 60%). Integrating clinical content with clinical teaching in a faculty development workshop is feasible, can improve clinical and teaching skills, and can facilitate behavior change