Clinical judgment, clinical training, and professional experience

Reviews studies on training, experience, and clinical judgment. The results on the validity of judgments generally fail to support the value of on-the-job experience in mental health fields. The validity results do provide limited support for the value of training. Other results suggest that experienced clinicians are better than less experienced judges at knowing which of their judgments are likely to be correct and which are likely to be wrong. Reasons why clinicians have trouble learning from experience are given. Recommendations are made for improving training and clinical practice.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

Physicians' Silent Decisions: Because Patient Autonomy Does Not Always Come First

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions—not all—are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time.     

Recognizing Racit Knowledge in Medical Epistemology

The evidence-based medicine movement advocates basing all medical decisions on certain types of quantitative research data and has stimulated protracted controversy and debate since its inception. Evidence-based medicine presupposes an inaccurate and deficient view of medical knowledge. Michael Polanyi’s theory of tacit knowledge both explains this deficiency and suggests remedies for it. Polanyi shows how all explicit human knowledge depends on a wealth of tacit knowledge which accrues from experience and is essential for problem solving. Edmund Pellegrino’s classic treatment of clinical judgment is examined, and a Polanyian critique of this position demonstrates that tacit knowledge is necessary for understanding how clinical judgment and medical decisions involve persons. An adequate medical epistemology requires much more qualitative research relevant to the clinical encounter and medical decision making than is currently being done. This research is necessary for preventing an uncritical application of evidence-based medicine by health care managers that erodes good clinical practice. Polanyi’s epistemology shows the need for this work and provides the structural core for building an adequate and robust medical epistemology that moves beyond evidence-based medicine.An erratum to this article can be found at     

The Care of the Ultra-Orthodox Jewish Patient

The Ultra-Orthodox Jewish community embraces a system of values and a rigorous behavioral code that are deeply rooted in religious tradition and history. Here we describe some of the unique challenges that stem from the encounter between modern medical practice and the Ultra-Orthodox world. Through examples of clinical and ethical scenarios ranging from prenatal care to end-of-life decisions, we illustrate problems related to observance of age-old practices in a modern hospital setting, balancing acceptance of Divine will with standard risk assessment, reconciliation of patient autonomy with deference to rabbinic authority and fear of stigma associated with mental illness in a traditional society. We also offer a generalizable model where inquiry precedes pre-formulated judgment to help clinicians provide enhanced care for this population.     

Physicians' silent decisions: because patient autonomy does not always come first

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions--not all--are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time.     

What the Problem May Be With Family Intervention … and With Dissemination More Generally: A Commentary

While the two decades since the study by Kavanagh et al. (1993) has given additional insights into effective dissemination of family interventions, the accompanying papers show that progress remains limited. The effectiveness trial that triggered this series of papers offers a cautionary tale. Despite management support, 30–35 hr of workshop training and training of local supervisors who could act as champions, use of the full intervention was limited. In part, this seemed due to the demanding nature of the intervention and its incompatibility with practitioners' roles, in part, to limitations in the training, among other factors. While the accompanying papers note these and other barriers to dissemination, they miss a more disturbing finding in the original paper: Practitioners said they were using several aspects in routine care, despite being unable to accurately describe what they were. This finding highlights the risks in taking practitioners' reports of their practice in files or supervision sessions at face value and potentially has implications for reports of other clinical work. The fidelity of disseminated treatments can only be assured by audits of practice, accompanied by affirming but also corrective feedback.     

Suicide risk assessment: Clinicians’ confidence in their professional judgment

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks to the need for ongoing training, consultation, and increased decision support strategies.     

Metacognitive monitoring during criterion learning: When and why are judgments accurate?

Research on metacognitive judgment accuracy during retrieval practice has increased in recent years. However, prior work had not systematically evaluated item-level judgment accuracy and the underlying bases of judgment accuracy in a criterion-learning paradigm (in which items are practiced until correctly recalled during encoding). Understanding these relationships during criterion learning has important theoretical implications for self-regulated learning frameworks, and also has applied implications for student learning: If the factors that influence metacognitive judgments are not predictive of subsequent test performance, students may make poor decisions during self-regulated learning. In the present experiments, participants engaged in test–restudy practice until items were recalled correctly. Once a given item reached criterion, participants made an immediate or delayed judgment of learning (JOL) for the item. A final cued-recall test occurred 30 min later. We examined judgment accuracy (the relationship between JOLs and test performance) and the underlying bases of judgment accuracy by evaluating cue utilization (the relationship between cues and JOLs) and cue diagnosticity (the relationship between cues and test performance). Immediate JOLs were only modestly related to subsequent test performance, and further analyses revealed that the cues related to JOLs were only weakly predictive of test accuracy. However, delaying JOLs improved both the accuracy of the JOLs and the diagnosticity of the cues that influenced judgments.     

Federal Funds to Train Clinical Psychologists for Work with Underserved Populations: The Bureau of Health Professions Graduate Psychology Education Grants Program

This paper describes the Bureau of Health Professions (BHPr) Graduate Psychology Education program (GPE), which supports projects that train health service psychologists for work with underserved populations. BHPr history and funding criteria are discussed, as are those of BHPr's parent organization, the Health Resources Service Administration. BHPr objectives and methods for support of clinical psychology training parallel those that BHPr has used to support training in other heath professions. The paper also describes three psychology internship training programs in academic medical settings that competed successfully for BHPr GPE funding in 2002. The three training projects differ significantly in training rotation sites, target populations with which trainees work, and the other health care professions that partner with psychology in interdisciplinary training—but they are similar in that each project provides an example of a program that effectively satisfied BHPr criteria for expanding psychology's scope of practice with underserved populations.     

Preschool Teacher Support Through Class-Wide Intervention

Abstract

Preparing professionals for class-wide consultation has a significant role in achieving goals associated with recent legislation and reform initiatives. Class-wide interventions are used to target achievement and social learning, are under a teacher's control and responsibility, and build on basic classroom interactions, routines, and resources. However, teachers may require considerable contextual appraisal and support from consultants. The purpose of this paper is to describe a teacher- support program evolving from Head Start consultations by school psychology students. Implications for training and practice are discussed.     

The Theory and Practice of Foreign Policy Decision Making

Central to Alex George's work was a concern with the psychology of presidential decision making. Our analysis focuses on George's work at the intersection of leadership psychology and the psychology of judgment in the making of consequential foreign policy decisions, specifically those dealing with issues of war and peace. We begin with a review of the fundamental dilemmas of political decision making, focusing on the various factors that present challenges to leaders seeking to make high-quality decisions. We then move to an analysis of the nature of judgment and the ways in which it both shapes and is shaped by cognitive dynamics and conclude by examining a number of steps designed to help leaders avoid the most damaging blind spots of their own psychologies and cognitive biases.     

Seeking an Analytic Identity

Abstract

Rothstein has stimulated all analysts to rethink how we can better commit ourselves to our analytic work. In this paper I focus on factors in analysts' personalities and experiences in their training and practice that contribute to or distract from establishing an analytic identity.

First, I explore analysts' background and motivation. In admissions to psychoanalytic institutes we look for candidates who can see psychoanalysis as an intellectual puzzle to be solved and an emotional involvement to be experienced. We look for earlv conflicts that the candidate can sublimate in the service of analytic functioning. We assume that the capacity to sublimate is only partial and that analysts in their development continue to recognize conflicts in transference—countertransference reactions.

Second, I give some examples of experiences from analysts' training that stimulate the formation of their analytic identities. These include transient identifications and counter-identifications with the training analyst, supervisor, seminar leader, and favorite analytic authors.

Third, I discuss more external factors that influence the development of analytic identity. These include the climate in training and continuing education at the institute. How much does the institute support its members in immersion in psychoanalysis? Economic factors continue to he an important factor in determining individual choice in this immersion.

Finally, I review studies on the effectiveness of psychoanalysis. Dedicated analysts with considerable experience believe that analysis works despite some limitations. Part of high motivation to continue analytic work includes understanding how analytic results differ from the simpler solutions achieved by nonanalytic therapies.     

Klinisch-psychologische Interventionen mit Mobilmedien

The internet gained popularity in the mid-nineties; its integration into psycho-social health care structures has been established in the meantime. The mobile communication boom followed in the early years of the second millennium. Within a very short time, the cellular phone has become a personal multi-purpose tool. Against this background it seems obvious to investigate to what extent mobile media, beside the internet, can meaningfully support clinical practice. This article gives an overview of the current research and development status of clinical-psychological intervention with the aid of computer-based mobile media (Mobile Therapy, abbr. M-Therapy). Contrary to a desktop with internet access, where its use is limited to certain areas, wireless mobile media have the ability to instantly collect clinically relevant data, complete training units or organize contacts to therapists. Pilot projects and first evaluation studies show that, for example, cellular phones, game consoles and handhelds are productive in psychological diagnostics, counseling, rehabilitation and therapeutic support. They are widely accepted and increase the effectiveness of therapy. We will discuss the media-specific opportunities and limitations of M-Therapy as well as its implications for clinical practice.     

Thinking,Doing, and the Ethics of Family Therapy

In this article, we examine how family therapists develop their capacity to make ethical decisions in clinical practice. We present an approach to clinical ethics that builds upon, and integrates the central features of, professional training and development in family therapy itself. We also explore the similarities and differences between the theoretical, top-down approach of bioethics, with its emphasis on “principled decision making,” and the clinical, pragmatic, bottom-up approach discussed here.     

Clinical versus actuarial prediction: a review of the literature.

Decisions made by psychologists can have considerable consequences on people's lives. Their decisions could be based on clinical judgment or empirically derived formulas. These two alternatives created a controversy concerning clinical and actuarial prediction. This controversy has been in existence for almost 70 years. During this time hundreds of articles have been published on this topic. This paper contains a review of the findings and issues on clinical versus actuarial prediction. The main conclusions are that (1) linear models are superior to other mathematical models of human judgment, (2) actuarial methods are more accurate than clinical prediction in many situations, (3) human judgment is flawed, and (4) actuarial methods are rarely employed in practice for a variety of reasons.     

Fitting model-based psychometric functions to simultaneity and temporal-order judgment data: MATLAB and R routines

Research on temporal-order perception uses temporal-order judgment (TOJ) tasks or synchrony judgment (SJ) tasks in their binary SJ2 or ternary SJ3 variants. In all cases, two stimuli are presented with some temporal delay, and observers judge the order of presentation. Arbitrary psychometric functions are typically fitted to obtain performance measures such as sensitivity or the point of subjective simultaneity, but the parameters of these functions are uninterpretable. We describe routines in MATLAB and R that fit model-based functions whose parameters are interpretable in terms of the processes underlying temporal-order and simultaneity judgments and responses. These functions arise from an independent-channels model assuming arrival latencies with exponential distributions and a trichotomous decision space. Different routines fit data separately for SJ2, SJ3, and TOJ tasks, jointly for any two tasks, or also jointly for the three tasks (for common cases in which two or even the three tasks were used with the same stimuli and participants). Additional routines provide bootstrap p-values and confidence intervals for estimated parameters. A further routine is included that obtains performance measures from the fitted functions. An R package for Windows and source code of the MATLAB and R routines are available as Supplementary Files.     

Enhancing job-site training of supported workers with autism: a reemphasis on simulation

Currently recommended practice in supported work emphasizes training job skills to workers with severe disabilities while on the job. Early behavioral research indicated that skills needed in natural environments could also be trained in simulated settings. We compared job-site plus simulation training for teaching job skills to supported workers with autism to provision of training exclusively on the job. Job-site training occurred in a small publishing company during the regular work routine, and simulation training occurred in an adult education site for people with severe disabilities. Two pairs of workers received training on two job skills; one skill was trained at the job site and the other was trained using job-site plus simulation training. Results indicated that for 3 of the 4 comparisons, job-site plus simulation training resulted in a higher level of skill or more rapid skill acquisition than did job-site-only training. Results suggested that job-site training, the assumed best practice for teaching vocational skills, is likely to be more effective if supplemented with simulation training. Directions for future research include expanding applications of behavioral technologies to other aspects of the current support paradigm.     

Bailing and jailing the fast and frugal way

Legal decisions such as the decision to bail upon adjourning a case have major consequences for both defendants and society. In the English system, magistrates, most of whom are lay people, are afforded considerable discretion and must work under constraints such as time pressure. Judgment analysis of the bail decision making policies of 81 magistrates from 44 courts throughout England and Wales revealed intra‐ and inter‐magistrate inconsistency in bail decisions, discrepancies between stated and elicited cue use, and high levels of post‐decisional confidence. Furthermore, magistrates' policies were better described and predicted by a fast and frugal model characterized by noncompensatory cue use, than by either of two compensatory integration models. The fast and frugal model portrays a picture of bail decision making that conflicts with the ideal practice as defined by the due process model of justice. We discuss the implications of these findings for judgment and decision making research and criminal justice policy. Copyright © 2001 John Wiley & Sons, Ltd.