Knowledge restructuring in expertise development: Evidence from pathophysiological representations of clinical cases by students and physicians

The present study was conducted to investigate qualitative changes that occur in the structure of knowledge in acquiring medical expertise. Therefore, the representation of pathophysiological knowledge was compared in subjects at four different levels of expertise. Subjects studied four clinical cases under three different time constraints, and provided a diagnosis and a pathophysiological explanation for the signs and symptoms in each case. Both diagnostic accuracy and quality of explanations increased with level of expertise. The explanations of experts, however, were less elaborate and less detailed than those of students. Constraining processing time affected the quality of explanations of advanced students, but not that of experts; conversely, the elaborateness and level of detail of explanations was affected in experts but not in students. The findings are explained by a network model integrating the two-world hypothesis in which biomedical and clinical knowledge are organised as two worlds apart (Patel, Evans, & Groen, 1989a, b) and the hypothesis of knowledge encapsulation in which biomedical knowledge becomes encapsulated into clinical knowledge (Schmidt & Boshuizen, 1992).     

On the Role of Biomedical Knowledge in Clinical Reasoning by Experts,Intermediates and Novices

In two studies the role of biomedical knowledge in the diagnosis of clinical cases was explored. Experiment 1 demonstrated a decrease in the use of biomedical knowledge with increasing expertise. This result appeared to be at variance with some findings reported in the literature (e.g., Lesgold, 1984), but supported those of others (e.g., Patel, Evans, & Groen, 1989). In Experiment 2, three possible explanations for this phenomenon were investigated: (1) rudimentation of biomedical knowledge, (2) inertia, and (3) encapsulation of biomedical knowledge under higher order concepts. Using a combined think-aloud and post-hoc explanation methodology, it was shown that experts have more in-depth biomedical knowledge than novices and subjects at intermediate levels of expertise. The findings generally support a three-stage model of expertise development in medicine consisting of acquisition of biomedical knowledge, practical experience, and integration of theoretical and experiental knowledge resulting in knowledge encapsulation.     

专家医生的知识结构及诊断推理方式

医学专长研究中“中间者效应”的发现,引发了研究者对专家医生知识结构的探讨。在“知识打包”的基础上,医生的临床知识以“疾病脚本”的方式组织起来。随着临床经验的增加,专家医生积累了丰富的疾病脚本。在临床诊断中,他们无需对病人所有的体征和症状进行仔细地和系统地分析,而是通过非分析性的推理方式——“模式识别”或“样例识别”便可自动激活与之匹配的疾病脚本,据此对病人做出迅速而准确的诊断。医学专长的本质就在于专家医生以“疾病脚本”的方式组织起来的知识结构。“适应性专长”代表了未来医学专长研究的新方向     

A study of the foundations of ethical decision making of clinical medical ethicists

A study of clinical medical ethicists was conducted to determine the various philosophical positions they hold with respect to ethical decision making in medicine and their various positions' relationship to the subjective-objective controversy in value theory. The study consisted of analyzing and interpreting data gathered from questionnaires from 52 clinical medical ethicists at 28 major health care centers in the United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, i.e., believe that value judgments are knowledge claims capable of being true or false and therefore expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world. In addition, the study revealed that most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making, i.e., in decision making regarding values they tend not to hold beliefs which are incompatible with other beliefs they hold about values.     

The importance of a holistic concept of health for health care. Examples from the clinic

One of my main points in this study is that the knowledge of orthodox medical theory is an incomplete guide for practical action when relating to our patients' specifically human problems. By following a holistic perspective on patients' health and on our medical enterprise we will be more efficient as doctors. This standpoint is illuminated by means of two case reports. Instead of focusing on symptoms as such and letting them refer to orthodox medical theory, I explicitly relate to the patients as if they are conveying a personal meaning by means of experienced symptoms. The experience of illness could be a successful strategy on the existential level although destructive on the technical biological level. A holistic theory of health can give doctors a good conceptual base when relating to people whose presented illnesses are to be regarded explicitly as their way of making themselves understood. The doctor's understanding of the patient's illness, of the theory of health, and of how health is regained, is dependent on the doctor's having the courage to reduce the distance to the patient, the courage to participate and be changed.     

The causal explanatory functions of medical diagnoses

Diagnoses in medicine are often taken to serve as explanations of patients’ symptoms and signs. This article examines how they do so. I begin by arguing that although some instances of diagnostic explanation can be formulated as covering law arguments, they are explanatory neither in virtue of their argumentative structures nor in virtue of general regularities between diagnoses and clinical presentations. I then consider the theory that medical diagnoses explain symptoms and signs by identifying their actual causes in particular cases. While I take this to be largely correct, I argue that for a diagnosis to function as a satisfactory causal explanation of a patient’s symptoms and signs, it also needs to be supplemented by understanding the mechanisms by which the identified cause produces the symptoms and signs. This mechanistic understanding comes not from the diagnosis itself, but rather from the theoretical framework within which the physician operates.     

Reasoning and Instruction in Medical Curricula

We describe two experiments that examine the knowledge and explanatory processes of students in two medical schools with different modes of instruction. One school had a conventional curriculum with basic science courses taught 1 '/2 years before the clinical training; the other had a problem-based learning curriculum with basic science taught in the context of clinical problems and general problem-solving strategies involving knowledge elaboration and hypothetico-deductive reasoning. Both before and after being exposed to relevant basic science information, students were asked to provide diagnostic explanations of a clinical case. In this study, students in the problem-based learning curriculum reasoned in a manner consistent with the way they were taught, using a backward directed pattern of reasoning and extensive elaborations based on detailed biomedical information. However; these students had a greater tendency to commit errors of scientific fact, to generate less coherent explanations, and to use flawed patterns of explanation, such as circular reasoning. These results are viewed as reflecting the operation of two factors: context and method of instruction. The interaction between these factors is expressed in terms of the hypothesis that basic science and clinical knowledge constitute two different worlds.     

Trans-parency in the workplace: How the experiences of transsexual employees can be improved

Very little research has focused exclusively on the workplace experiences of transsexual employees. Studies that have been done are either qualitative case studies (e.g., Budge, Tebbe, & Howard; 2010; Schilt & Connell, 2007), or aggregate transsexual individuals with lesbian, gay, and bisexual employees (e.g., Irwin, 2002). The current study focuses on this underexamined population and examines general workplace experiences, and both individual and organizational characteristics that influence transsexual employees' job attitudes. Results reveal that organizational supportiveness, transsexual identity centrality, and the degree to which they disclose to individuals outside of work all predict transsexual employees' disclosure behaviors in the workplace. These disclosure behaviors are positively related to job satisfaction and organizational commitment, and negatively related to job anxiety. These relations are mediated by coworker reactions. This research expands knowledge about diverse employee populations and offers both theory and some of the first large-scale empirical data collected on the workplace experiences of transsexual employees.     

When Anxiety Symptoms Masquerade as Medical Symptoms: What Medical Specialists Know about Panic Disorder and Available Psychological Treatments

Under-recognition of somatic symptoms associated with panic in primary care settings results in unnecessary and costly diagnostic procedures and inappropriate referrals to cardiologists, gastroenterologists, and neurologists. In the current study specialists’ knowledge regarding the nature and treatment of panic were examined. One-hundred and fourteen specialists completed a questionnaire assessing their knowledge about panic attacks, including their perceptions of psychologists’ role in treating panic. Respondents answered 51% of knowledge items correctly. Although most knew the definition of a panic attack, they knew less about clinical features of panic and its treatment. Specifically, whereas 97.4% believed medication effectively relieves panic symptoms, only 32.5% knew that cognitive-behavioral therapy (CBT) is a first-line treatment. Only 6% reported knowing how to implement CBT, and only 56.1% recognized that psychologists could effectively treat panic. These findings demonstrate significant gaps in specialists’ knowledge about panic and the need to enhance physician knowledge about panic attacks and their treatment.     

Technical Knowledge,Prosocial Knowledge,and Clinical Performance of Indian Medical Students

We cross‐culturally replicated and extended findings reported by Kell, Motowidlo, Martin, Stotts, and Moreno that technical knowledge and prosocial knowledge have independent effects on performance. In a sample of 196 Indian medical students, we found that prosocial knowledge explains variance in students' clinical performance beyond the variance explained by technical knowledge and technical knowledge explains variance in clinical performance beyond the variance explained by prosocial knowledge. Contrary to findings that American medical students' prosocial inclinations, as reflected in measures of empathy, seem to decline over the course of their medical training (e.g., Hojat, Vergare, Maxwell, Brainard, Herrine, and Isenberg), we found that Indian medical students' prosocial knowledge steadily increased from their third to fifth years of medical study.     

Encoding time and signs exposure time in the representation of diagrammatic deontic meanings

It has been proposed that prohibition and obligation be represented in different ways in reasoning with deontic information (Bucciarelli & Johnson-Laird, 2005). Obligations are salient in permissible situations and prohibitions in impermissible situations. In some specific cases, differential initial representations are also consistently predicted from the comprehension of negations, if prohibition is considered as the negation of an obligation. Three experiments evaluate whether traffic signs of prohibition and obligation speed up the response time to the proposed direction represented and whether this advantage remains when people have more time to think. When making judgements about the manoeuvre performed by a vehicle, participants' response times are consistent with the predicted representation when they have a short time (i.e., 300 ms) to understand the premise. In this case they represent what is permissible by obligatory signs and also what is impermissible by prohibitory signs. However, if they have more time (i.e., 1000 ms) to understand the premise, they still represent what is permissible by obligatory signs but they seem to change their initial representations to what is permissible by prohibitory signs.     

Parsing as deduction: The use of knowledge of language

Hypothesising that the human parser is a specialized deductive device in which Universal Grammar and parameter settings are represented as axioms provides a model of how knowledge of language can be put to use. The approach is explained via a series of model deductive parsers for Government and Binding Theory, all of which use the same knowledge of language (i.e., underlying axiom system) but differ as to how they put this knowledge to use (i.e., they use different inference control strategies). They differ from most other GB parsers in that the axiom system directly reflects the modular structure of GB theory and makes full use of the multiple levels of reprepresentation posited in GB theory.     

Reply to lokhandwala and westefeld

Abstract

Lokhandwala and Westefeld's article highlighting the ethical dilemma in rational suicide raises the pragmatic question of how one would actually assess a client's situation. A particularly relevant diagnosis that should be ruled out is clinical depression. The DSM-IV lists nine symptoms of major depressive disorder, eight of which could easily be masked as symptoms of the physical illness or side effects of treatment. These symptoms can be grouped into three categories: central features of depression, physical signs of depression, and cognitive signs of depression. All three of these categories, particularly physical signs, could easily be mistaken for medical problems. Reviewing the nine criteria for a diagnosis of clinical depression might be a good way to explore the possibility of clinical depression in a terminally ill person who is supposedly making a “rational” decision to commit suicide.     

A multimodal behavior analytic model for evaluating the effects of medical problems on nonspecific behavioral symptoms in persons with developmental disabilities

A relationship between various medical illnesses and the frequency and severity of nonspecific behavioral symptoms such as aggression and self-injury has been described by a number of writers. None, however, provides a clinical case formulation model that articulates the specific nature of this relationship or the manner in which potential biomedical influences interact with psychological and socioenvironmental ones to determine the occurrence and strength of behavioral symptoms. A model is described in this paper that suggests possible contributions of medical illnesses or conditions to occurrence of nonspecific behavioral symptoms and provides a diagnostic basis for selecting and evaluation related interventions. © 1997 John Wiley & Sons, Ltd.     

试论张仲景辩病结合辩证的辨证论治方法的先进性

张仲景辩病结合辩证的辨证论治方法,与现代医学认识疾病的思想非常近似,通过比较现代医学认识疾病思想与张仲景疾病认识概念在疾病诊治过程中的相似性,为研究<金匮要略>古代疾病与西医现代病的对应性结合、提高病证结合论治在临床的效验,有很大意义.     

PSYKOANALYSE I DAG

The original psychoanalytic research situation is the two-person dialogue. However, clinical practice in itself is still not an application of systematic case study methodology. In order to approach the question of why we need systematic psychoanalytic research, three types of dialectical tensions are described. Psychoanalysis, like other scientific disciplines, is involved in a dialectics of (1) rationalism versus empiricism, i.e., theory construction and observation; (2) the perspective from within and from without, i.e., subjective self-knowledge versus expert knowledge; (3) continuity or discontinuity between psychoanalysis and adjacent fields of knowledge, as well as realism versus essentialism. The tension between the scientific and the clinical attitudes is discussed. Finally, the question of scientific and private theories is approached. Some of the methodological and epistemological pitfalls in psychoanalysis are seen as a consequence of the close affinity between private explanatory systems and psychoanalytical theories. Rules of evidence are necessary as a control for the unavoidable uncertainty.