38 research outputs found
Clinical decision making in the recognition of dying: a qualitative interview study
BACKGROUND: Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: "What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?" METHODS: This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti. RESULTS: Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition. CONCLUSIONS: This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers
Use of inductive, problem-based clinical reasoning enhances diagnostic accuracy in final year veterinary students
Despite tremendous progression in the medical field, levels of diagnostic error remain unacceptably high. Cognitive failures in clinical reasoning are believed to be the major contributor to diagnostic error. There is evidence in the literature that teaching problem-based, inductive reasoning has the potential to improve clinical reasoning skills. In this study, 47 final-year veterinary medicine students at the Royal Veterinary College (RVC) were presented with a complex small animal medicine case. The participants were divided into two groups, one of which received a prioritized problem list in addition to the history, physical exam, and diagnostic test results provided to both groups. The studentsâ written approaches to the case were then analyzed and assigned a diagnostic accuracy score (DAS) and an inductive reasoning score (IRS). The IRS was based on a series of predetermined characteristics consistent with the inductive reasoning framework taught at the RVC. No significant difference was found between the DAS scores of each group, indicating that the provision of a prioritized problem list did not impact diagnostic accuracy. However, a significant positive correlation between the IRS and DAS was illustrated for both groups of students, suggesting increased use of inductive reasoning is associated with increased diagnostic accuracy. These results contribute to a body of research proposing that inductive, problem-based reasoning teaching delivered in an additive model, can enhance the clinical reasoning skills of students and reduce diagnostic error
Une intelligence artificielle raisonne-t-elle de la mĂȘme façon que les cliniciens pour poser des diagnostics ?
Quâest-ce qui motive [ou non] les Ă©tudiants en mĂ©decine Ă choisir comme spĂ©cialitĂ© la mĂ©decine dâurgence ?
Objectif: Le diplĂŽme dâĂ©tudes spĂ©cialisĂ©es de mĂ©decine dâurgence a Ă©tĂ© crĂ©Ă© en France Ă la rentrĂ©e universitaire 2017. En 2018, 21 postes ont Ă©tĂ© laissĂ©s vacants aux Ă©preuves classantes nationales (ECN). Cette Ă©tude avait pour but dâidentifier les raisons pour lesquelles les Ă©tudiants souhaitent ou non choisir la mĂ©decine dâurgence, ainsi que leur motivation pour cette spĂ©cialitĂ©. MatĂ©riel et mĂ©thodes: Nous avons menĂ© une Ă©tude observationnelle prospective et monocentrique. Tous les Ă©tudiants du premier et du deuxiĂšme cycle de la facultĂ© de mĂ©decine de Strasbourg ont Ă©tĂ© sollicitĂ©s entre 2017 et en 2018. Des questionnaires ont Ă©tĂ© autoadministrĂ©s en prĂ©sentiel ou en ligne afin de recueillir le type de spĂ©cialisation envisagĂ©, le degrĂ© de motivation des rĂ©pondants pour devenir mĂ©decin urgentiste et lâinfluence de diffĂ©rents facteurs motivationnels sur leur volontĂ© ou non de choisir la mĂ©decine dâurgence aux ECN RĂ©sultats: Sept pour cent des Ă©tudiants de premiĂšre annĂ©e de mĂ©decine souhaitent choisir la mĂ©decine dâurgence comme spĂ©cialitĂ©. Ils ne sont plus quâun pour cent en sixiĂšme annĂ©e. Le mode de vie est considĂ©rĂ© de façon croissante entre le dĂ©but et la fin des Ă©tudes prĂ©graduĂ©es comme particuliĂšrement dissuasif. La variĂ©tĂ© des pathologies rencontrĂ©es et le dĂ©fi intellectuel sont des facteurs attractifs et stables. Conclusion:LâattractivitĂ© de la mĂ©decine dâurgence pourrait ĂȘtre renforcĂ©e en communiquant auprĂšs des Ă©tudiants en mĂ©decine de deuxiĂšme cycle sur les facteurs sources de motivation et en poursuivant la rĂ©flexion visant Ă amĂ©liorer la qualitĂ© de vie des mĂ©decins urgentiste
The culture of doubt: Do medical students really experience clinical uncertainty when they should?
International audienceUncertainty is a fundamental aspect of medical practice, necessitating incorporation into undergraduate medical training. The integrative model of uncertainty tolerance (UT) developed by Hillen and Han serves as a comprehensive framework for exploring clinical uncertainty. While studies have extensively examined UT dimensions, including sources, responses, and moderators, the factors influencing the perception of uncertainty stimuli remain underexplored. However, studentsâ ability to perceive uncertainty and their approach to uncertain stimuli play a crucial role in enabling them to develop adaptive responses to uncertainty, necessary for their comfort in these situations. Defining uncertainty as a metacognitive state suggests significant variability in its perception among individuals and within an individual over time. Moreover, several studies have demonstrated the substantial influence of various individual and contextual factors on how individuals perceive and respond to uncertainty. In this paper, the authors present multiple hypotheses to address the question of whether students genuinely perceive uncertainty stimuli when they should. The authors argue that studentsâ personal relationship with their knowledge is essential in their ability to identify clinical uncertainty, particularly concerning the limits of medical knowledge. Therefore, they propose that an academic culture fostering doubt, through exposing students to a variety of perspectives, would enhance their ability to identify uncertainty zones in a clinical situation at an early stage. Drawing on Deweyâs situational theory, the authors emphasize the importance of better understanding, in a work setting, the influence of contextual and situational characteristics on individual perceptions of uncertainty. In line with this idea, ethnographic studies would offer valuable insights into identifying the relationship between the students, their work environment, and their perception of clinical uncertainty
FEM validation of front end and back end defects evolution in AA6063 and AA6082 aluminum alloys profiles
The reduction of scraps related to back end defects (i.e. billet skin contamination) and front end defects (i.e. charge welds) is gaining nowadays an increasing industrial interest in order to obtain greater process efficiency. Today, extrusion industrial practice faces the issue by means of technician's experience, empirical rules or, in most critical profiles, through time consuming and expensive experimental analyses. On the other side, FEM simulation of extrusion dies is becoming a common support tool for the design of new critical dies. Stating this scenario, the possibility to include the prediction of front end and back end defects evolution as simulation output can then be easily obtained at almost comparable computational costs. In this paper the FEM code Altair HyperXtrude\uae is used for the simulation of 2 industrial cases made by AA6063 and AA6082 alloys following the transient moving boundaries approach. Experimentally, the profiles were extruded, sectioned, polished and etched with caustic soda in order to reveal and measure front and back end development in front of and behind the profile stop mark. The data obtained from experimental analyses are initially discussed referring to billet skin contamination and charge weld evolution, then compared to industrial experience, to theoretical and empirical methods available in literature and to FEM results in order to evaluate pros and cons of each evaluation method
Finite Element Model Prediction of Charge Weld Behaviour in AA6082 and AA6063 Extruded Profiles
Charge welds are unavoidable defects of the continuous extrusion process whose extension needs to be accurately predicted in order to avoid profile mechanical failures or to minimize unrequired scrap of material. The aim of this work was then to evaluate the accuracy of the charge welds FEM predictions and their applicability in the industrial field. Two different industrial cases involving A6082 and AA6063 aluminium alloys were analysed. The data of charge welds behaviours were experimentally collected, discussed and then innovatively compared to the predicted outcomes of FEM simulations performed using QForm Extrusion\uae software and of theoretical formulas reported in the literature. As main results, a very good numerical-experimental matching was found, with a peak discrepancy of 122 mm in terms of charge weld extent, while theoretical formulas returned a significant underestimation