RESUMEN
Dutch medical disciplinary boards consider physicians' gut feelings an element of the professional standards. Some indications can be found in the international literature suggesting intuitive feelings of unease of patients or their relatives can also contribute to adequate diagnostics. What is the view of disciplinary boards on this? A search in the disciplinary boards' database (2010-2017) found 55 rulings where the search term 'ongerust' (worried) was related to a patient, family member or partner and 51 rulings where the term 'bezorgd' (concerned) was related to a patient, family member or partner. The disciplinary boards expect that doctors are prepared to discuss worry and concern with their patients. Additionally, they consider patients' worry and concern to be a useful part of the doctors' diagnostics, which may possibly result in reviewing the diagnosis. This is consistent with the international literature.
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Toma de Decisiones Clínicas/métodos , Intuición , Médicos/psicología , Emociones , Consejo Directivo , Humanos , Países Bajos , Relaciones Médico-Paciente , Médicos/organización & administraciónRESUMEN
What role does uncertainty play in the doctor's diagnostic reasoning process? Would it not be better to avoid uncertainty as much as possible? In this article we answer this question from an epistemological perspective. Doctors build up relevant, situational knowledge during the diagnostic process through listening, observation and interpretation during their contact with the patient. Uncertainty can play a crucial role in this. We use a practical case to illustrate how allowing in some uncertainty - in the form of gut feelings - can improve the quality of the diagnostic thought process.
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Toma de Decisiones Clínicas/métodos , Médicos/psicología , Solución de Problemas , Incertidumbre , Emociones , HumanosRESUMEN
OBJECTIVES: The validated Gut Feelings Questionnaire (GFQ) is a 10-item questionnaire based on the definitions of the sense of alarm and the sense of reassurance. The purpose of the GFQ is to determine the presence or absence of gut feelings in the diagnostic reasoning of general practitioners (GPs).The aim was to test the GFQ on GPs, in real practice settings, to check whether any changes were needed to improve feasibility, and to calculate the prevalence of the GPs' sense of alarm and sense of reassurance in three different countries. SETTING: Primary care, six participating centres in Belgium, France and the Netherlands. PARTICIPANTS: We performed a think-aloud study with 24 experienced Dutch GPs, GP trainees and medical clerks who filled in the GFQ after diagnosing each of six case vignettes. We then performed a feasibility study in two phases, using a mixed-method approach, with 42 French and Dutch GPs in the first phase and then 10 Belgian, 10 Dutch and 10 French GPs in the second phase. All GPs filled in the GFQ after each of eight consultations with patients presenting new complaints and were subsequently interviewed about the use of the GFQ. OUTCOME MEASURES: GPs' experiences on using the GFQ in real practice, more specifically the average time needed for filling in the questionnaire.The prevalence of GPs' sense of alarm and sense of reassurance. RESULTS: The modified version of the GFQ, created without altering the sense of the validated items, was easy to use in daily practice. The prevalence of the GPs' sense of alarm occurred during 23%-31% of the included consultations. CONCLUSIONS: After a two-step study and several minor adaptations, the final version of the GFQ proved to be a feasible and practical tool to be used for prospective observational studies in daily practice.
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Actitud del Personal de Salud , Toma de Decisiones , Medicina General/métodos , Médicos de Familia/psicología , Encuestas y Cuestionarios/normas , Adulto , Bélgica , Emociones , Estudios de Factibilidad , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Países BajosRESUMEN
CONTEXT: Medical experts have access to elaborate and integrated knowledge networks consisting of biomedical and clinical knowledge. These coherent knowledge networks enable them to generate more accurate diagnoses in a shorter time. However, students' knowledge networks are less organised and students have difficulties linking theory and practice and transferring acquired knowledge. Therefore we wanted to explore the development and transfer of knowledge of third-year preclinical students on a problem-based learning (PBL) course with real patient contacts. METHODS: Before and after a 10-week PBL course with real patients, third-year medical students were asked to think out loud while diagnosing four types of paper patient problems (two course cases and two transfer cases), and explain the underlying pathophysiological mechanisms of the patient features. Diagnostic accuracy and time needed to think through the cases were measured. The think-aloud protocols were transcribed verbatim and different types of knowledge were coded and quantitatively analysed. The written pathophysiological explanations were translated into networks of concepts. Both the concepts and the links between concepts in students' networks were compared to model networks. RESULTS: Over the course diagnostic accuracy increased, case-processing time decreased, and students used less biomedical and clinical knowledge during diagnostic reasoning. The quality of the pathophysiological explanations increased: the students used more concepts, especially more model concepts, and they used fewer wrong concepts and links. The findings differed across course and transfer cases. The effects were generally less strong for transfer cases. CONCLUSIONS: Students' improved diagnostic accuracy and the improved quality of their knowledge networks suggest that integration of biomedical and clinical knowledge took place during a 10-week course. The differences between course and transfer cases demonstrate that transfer is complex and time-consuming. We therefore suggest offering students many varied patient contacts with the same underlying pathophysiological mechanism and encouraging students to link biomedical and clinical knowledge.
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Diagnóstico Diferencial , Educación de Pregrado en Medicina/métodos , Aprendizaje Basado en Problemas/métodos , Estudiantes de Medicina , Competencia Clínica , Conocimientos, Actitudes y Práctica en Salud , Humanos , Países BajosRESUMEN
BACKGROUND: Family physicians perceive that gut feelings, i.e. a 'sense of reassurance' or a 'sense of alarm', play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning. METHODS: We constructed 16 case vignettes from real practice situations and used the accompanying 'sense of reassurance' or the 'sense of alarm' as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed. RESULTS: As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 - 0.72) and low for the ambiguous-case vignettes (0.08 - 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population's judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire's internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire. CONCLUSIONS: The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians' diagnostic reasoning.
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Toma de Decisiones , Diagnóstico , Intuición , Médicos de Familia/psicología , Encuestas y Cuestionarios , Análisis Factorial , Medicina Familiar y Comunitaria/métodos , Humanos , Análisis de Componente Principal , Investigación Cualitativa , Reproducibilidad de los ResultadosRESUMEN
CONTEXT: Real-patient contacts in problem-based undergraduate medical education are promoted as a good way to introduce biomedical and (in)formal clinical knowledge early in the curriculum and thereby to foster the development of coherent and integrated knowledge networks. There are concerns, however, that such contacts may cause students to focus on clinical knowledge to the neglect of biomedical knowledge, and that group discussions may be dominated by teachers. We examined these concerns by addressing the following questions in the context of group sessions in which students prepare for and report on real-patient contacts. To what extent are biomedical and (in)formal clinical knowledge addressed? To what extent are these knowledge types addressed by students or tutors? Are connections made between biomedical and clinical knowledge? METHODS: We videotaped and transcribed six preparation and six reporting group sessions (two preparation and two reporting phases for each of three groups) held with students in Year 3 of the problem-based curriculum at Maastricht University. During this year, real patients rather than paper patients are used. Qualitative analysis software was used to code propositions in the transcriptions in order to identify different kinds of knowledge and different functions of biomedical knowledge. RESULTS: Formal clinical knowledge was the subject of 40.7% and 34.8% of propositions during the preparation and reporting phases, respectively. The corresponding percentages for biomedical knowledge were 15.0% and 28.0%. Tutors accounted for 63.4% of propositions during the preparation phase, and students for 80.1% during the reporting phase. Nearly all biomedical knowledge was related to clinical knowledge. CONCLUSIONS: It appears that pre-clinical patient encounters can stimulate students to pay attention to both clinical and biomedical knowledge and to how they are connected. Tutor dominance was evident only during the preparation phase. Further research is needed to investigate whether pre-clinical patient contacts promote the development of coherent and integrated knowledge networks.
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Competencia Clínica/normas , Curriculum/normas , Educación de Pregrado en Medicina/métodos , Aprendizaje Basado en Problemas/métodos , Estudiantes de Medicina/psicología , Comunicación , Educación de Pregrado en Medicina/normas , Humanos , Educación del Paciente como Asunto , Pacientes/psicología , Relaciones Médico-Paciente , Aprendizaje Basado en Problemas/normas , Desempeño de Papel , Grabación de Cinta de VideoRESUMEN
Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians' learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients' conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians' learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.
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Competencia Clínica , Educación Médica Continua/métodos , Aprendizaje , Médicos , Desarrollo de Personal/estadística & datos numéricos , Adulto , Escolaridad , Retroalimentación , Femenino , Humanos , Masculino , Países Bajos , Pautas de la Práctica en Medicina , Solución de Problemas , Lugar de TrabajoRESUMEN
BACKGROUND: Worked examples are very effective for novice learners. They typically present a written-out ideal (didactical) solution for learners to study. AIMS: This study used worked examples of patient history taking in physiotherapy that presented a non-didactical solution (i.e., based on actual performance). The effects of model expertise (i.e., worked example based on advanced, third-year student model or expert physiotherapist model) in relation to students' expertise (i.e., first- or second-year) were investigated. SAMPLE: One hundred and thirty-four physiotherapy students (61 first-year and 73 second-year). METHODS: Design was 2 × 2 factorial with factors 'Student Expertise' (first-year vs. second-year) and 'Model Expertise' (expert vs. advanced student). Within expertise levels, students were randomly assigned to the Expert Example or the Advanced Student Example condition. All students studied two examples (content depending on their assigned condition) and then completed a retention and test task. They rated their invested mental effort after each example and test task. RESULTS: Second-year students invested less mental effort in studying the examples, and in performing the retention and transfer tasks than first-year students. They also performed better on the retention test, but not on the transfer test. In contrast to our hypothesis, there was no interaction between student expertise and model expertise: all students who had studied the Expert examples performed better on the transfer test than students who had studied Advanced Student Examples. CONCLUSIONS: This study suggests that when worked examples are based on actual performance, rather than an ideal procedure, expert models are to be preferred over advanced student models.
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Docentes , Anamnesis/métodos , Grupo Paritario , Especialidad de Fisioterapia/educación , Competencia Profesional , Enseñanza/métodos , Logro , Adolescente , Curriculum , Femenino , Humanos , Masculino , Limitación de la Movilidad , Países Bajos , Retención en Psicología , Rehabilitación de Accidente Cerebrovascular , Transferencia de Experiencia en Psicología , Adulto JovenRESUMEN
BACKGROUND: This study was directed at illuminating a well known phenomenon in the medical expertise literature, the 'intermediate effect' in clinical case recall. This robust phenomenon consists of the finding that medical students of intermediate levels of expertise outperform both experts and novices in clinical case recall after diagnosing cases. It deals in particular with the findings of OME researchers who have reported a monotonically increasing recall with level of expertise. PURPOSE: To address possible causes for this anomaly in medical expertise and to experimentally demonstrate how data elaboration can cause expertise effects in clinical case recall. METHOD: Expert nephrologists, intermediate level students and novices were presented with 6 medical cases under 3 different conditions: laboratory data cases without special instructions, laboratory data cases with instructions to elaborate, and cases with laboratory data and a relevant clinical context. RESULTS: Only when participants were required to elaborate on each of the information units presented to them did case recall show an expertise effect. If laboratory data are framed within the context of a patient's history and physical examination data, the 'intermediate effect' appears. CONCLUSIONS: The instructions used in the elaboration condition seem to have induced a deeper, more detailed, analysis of the patient case. It is therefore interesting to note that these instructions only affected the recall of the experts and had no effect on the novices' or intermediates' recall. We might conclude from this that expertise effects in clinical case recall are only produced when the normal processing of patient information is disrupted.
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Competencia Clínica/normas , Recuerdo Mental , Nefrología/normas , Médicos/normas , Estudiantes de Medicina , Humanos , Países Bajos , Médicos/psicología , Estudiantes de Medicina/psicología , PensamientoRESUMEN
BACKGROUND: Based on cognitive psychological research, a number of theoretical frameworks have been put forward to describe the structure of experts' medical knowledge and to explain experts' case-processing. PURPOSE: To provide evidence for the theory of knowledge encapsulation, which states that medical knowledge constitutes of interlinked biomedical and clinical knowledge. METHODS: Fourth-year medical students, clerks and medical experts evaluated six case descriptions, consisting of laboratory data either with or without a clinical context. For each case description, the participants were required to study the case, to formulate a diagnosis, and to write down everything they could remember of the case. RESULTS: When the laboratory data were not embedded within a clinical context, medical experts' case-processing increased and their diagnostic accuracy became worse. Furthermore, laboratory data recall of medical experts was more elaborate in cases where the laboratory data were presented without a clinical context. Similar results were obtained for students and clerks. CONCLUSIONS: The findings are only partially consistent with a prediction made by the theory of knowledge encapsulation. Further research, using a different paradigm than the traditionally used method of free recall, is required to unearth whether medical experts use qualitatively different knowledge structures than novices while solving cases.