A certain art of uncertainty: case presentation and the development of professional identity.

Healthcare professionals use the genre of case presentation to communicate among themselves the salient patient information during treatment and management. In case presentation, many uncertainties surface, regarding, e.g., the reliability of patient reports, the sensitivity of laboratory tests, and the boundaries of scientific knowledge. The management and portrayal of uncertainty is a critical aspect of professional discourse. This paper documents the rhetorical features of certainty and uncertainty in novice case presentations, considering their pragmatic and problematic implications for students' professional socialization. This study was conducted during the third-year inpatient clerkship at a tertiary care, pediatric hospital in hospital in Canada. Data collection included: (1) non-participant observations of 19 student case presentations involving 11 student and 10 faculty participants, and (2) individual interviews with 11 students and 10 faculty participants. A grounded theory approach informed data collection and analysis. Five thematic categories emerged, two of which this paper considers in detail: "Thinking as a Student" and "Thinking as a Doctor". Within these categories, the management and portrayal of uncertainty was a recurrent issue. Teachers modeled central features of a "professional rhetoric of uncertainty", managing uncertainty of six origins: limits of individual knowledge, limits of evidence, limitless possibility, limits of patient's/parent's account, limits of professional agreement, and limits of scientific knowledge. By contrast, students demonstrated a "novice rhetoric of uncertainty", represented by their focus on responding to personal knowledge deficits through the strategies of acknowledgement, argument, and deflection. Some students moved towards the professional rhetoric of uncertainty, suggesting not only advances in communication, but also shifts in attitude towards patients and colleagues, that were interpreted as indications that this rhetoric shapes professional identity and interactions.

Veterinary school admission interviews, part 2: survey of North American schools.

A study of veterinary school admission interview practices across the USA and Canada was conducted in 1999. All 31 schools responded. INTERVIEW USE: Eighty-four percent of the veterinary schools interview applicants. Veterinary schools are more likely to interview resident than non-resident applicants (62% interviewed >or=49% of their resident applicants, while 77% interviewed or=77%). The five most common characteristics and skills the veterinary admission interview is intended to assess are communication skills, maturity, motivation for and interest in veterinary medicine, interpersonal skills, and knowledge of the veterinary profession (>or=92%). The least common characteristic or skill the veterinary admission interview is intended to assess is academic performance (23%). INTERVIEW FORMAT: Veterinary schools are most likely to offer one interview to a candidate (83%). A panel interview with between two and three interviewers is the predominant format employed (92%). The interview is of 20-45 minutes duration (88%), most commonly 30 minutes (50%). Interview questions most often address experiences in veterinary medicine, general background, and strengths and weaknesses (>or=85%). The level of interview structure is low to moderate (73%). The cold or blind interview (where interviewers are denied access to all or part of the written application) is employed by 50% of the interviewing veterinary schools. INTERVIEWERS: Interviewing veterinary schools assign interviewing to faculty veterinarians (100%). Some level of interviewer training is usually provided (87%); the most common mode of training is distribution of printed material (86%). SUMMARY AND RECOMMENDATIONS: The veterinary admissions interview is similar to that employed by schools of medicine, optometry, and dentistry, with the exception that veterinary schools are more likely to use panel interviews, to fix the interview weight in selection decisions, and to employ a cold or blind interview (these differences provide an opportunity to increase interview reliability and validity). Interview reliability and validity can be further improved by increasing interviewer training and interview structure, ensuring that the interview's format is consistent with its purpose, and identifying behavioral characteristics that are consistent with successful practice.

Veterinary school admission interviews, part 1: literature overview.

An analysis of the admission interview used by schools in four health professions (veterinary medicine, allopathic medicine, optometry, and dentistry) portrays a largely similar approach to selection interviews: INTERVIEW USE: At least 80% of schools interview applicants. For schools that offer interviews, at least 40% of candidates are interviewed (a strong academic profile is the number one determinant of receiving an interview offer). The interview is one of the three most important selection tools used by schools. Less than 26% of schools fix the interview's weight in the selection process (fixed weights range from 31% to 35%). INTERVIEW PURPOSE AND CONTENT: The most common purposes of the interview are to (1) gather information, (2) make decisions, (3) verify information provided in other parts of the application, (4) recruit candidates, and/or (5) promote public relations. The most common characteristics and skills interviewers are interested in assessing are motivation for the profession, interpersonal skills, and communication skills. The desire to assess cognitive ability with the interview (>25% of schools) is surprising in view of the use of other selection tools (e.g., GPA). INTERVIEW FORMAT: Medical schools are more likely to offer two interviews per candidate, while optometry schools are more likely to offer one interview per candidate. Individual interviews (one interviewer, one candidate) are the predominant format among medical schools, while panel interviews (more than one interviewer, one candidate) are the most common format among optometry schools. The duration of the interview is 30 to 45 minutes. Interview questions most often address facts and knowledge, hypothetical situations, and the ability to meet program requirements. Most interviews do not meet the criteria for a structured interview, which has demonstrated greater validity and reliability than semi-structured or unstructured interviews. INTERVIEWERS: Interviewers are most likely to be health care faculty members (e.g., veterinarians at a veterinary school). Interviewers receive limited training. RECOMMENDATIONS FOR INCREASING INTERVIEW RELIABILITY AND VALIDITY: The purpose(s) of the interview must be clearly articulated so that the interview and interviewer training can be designed to achieve that purpose. Interview structure should be increased by developing a "job analysis" set of questions that is posed to all candidates and scored using behavioral anchors. Interviewers should receive more training in rater bias, listening skills, and interview structure. Panel interviews should be used to increase reliability. Interviewers should not have access to the candidate's application unless the interview is used to verify information. To increase the utility of the interview in the selection process, the weight of the interview in relation to other selection components should be determined.

Interview expectations and experiences of optometry applicants and interviewers.

This 1996 study examined the admission interview employed at the University of Waterloo School of Optometry (UWSO). A questionnaire was developed, piloted, and mailed to 157 UWSO applicants and 23 UWSO interviewers. Their expectations of an ideal optometry admission interview were compared with their experiences of the UWSO admission interview. The response rate was 71.7% (n = 129; 109 applicants, 20 interviewers). Statistical analysis involved principle component analysis and t-tests (independent and paired). Participants believed the ideal optometry admission interview should gather information, verify information, provide information, and select candidates by appraising their 'people skills,' 'professional skills,' and 'attitude orientation.' Although the participants' expectations of the ideal interview resembled the mission statement of the UWSO interview, the expectations, particularly among applicants, significantly deviated from their experiences of the UWSO interview.

Interview expectations and experiences of women and men applying to an optometry program.

Similar numbers of women and men are admitted to North American optometry programs. We question the notion that these data signify an admission process free of gender bias. This 1996 study of the University of Waterloo School of Optometry (UWSO) examines its admission interview. A written questionnaire was developed, piloted, and mailed to 157 applicants. Their expectations of an ideal optometry interview were compared with their experiences of the UWSO's interview. The response rate was 69.4% (N = 109; 62 women and 47 men). Statistical analyses involved principle component (PC) analysis and paired t-tests (p = 0.01). Women and men believed the UWSO interview was significantly inadequate in its attention to addressing public relations and verifying application information. In addition, women perceived the UWSO interview was significantly deficient in efforts to recruit candidates and gather candidate information.

Design elements of professional ethics courses.

Optometrists face ethical dilemmas daily in the practice of their profession. Students training to become optometrists also face ethical dilemmas, some of which are unique in their role as students. The focus on ethical practice has been heightened by the increasing scope of optometric practice, the greater demand of society for professional accountability, the greater diversity of membership and viewpoints, the decrease in available dollars for health care delivery, and the conflicting roles of ophthalmology and opticianry with optometry. These factors have led to the addition or expansion of professional ethics courses in optometry programs. This paper examines the difficulties inherent in defining professional ethics and designing ethics courses. Curricular issues are examined, including course objectives, instructors, content, evaluation, timetabling, teaching strategies, student assessment, and resource implications. Much of the research in this area has been done in medical education. Although the content of ethical dilemmas encountered by medical students and physicians may not be applicable to optometry, the process by which they learn to approach the dilemmas is the same.

Optometry admission interviewing practices in Canada and United States.

This study of optometry programs in Canada and the United States identified both the extent of and approach to admission interviewing as well as the reasons for its inclusion or exclusion. A written questionnaire was designed, piloted, and revised before it was sent to each of the 18 optometry programs. The 15 (83%) completed questionnaires were analyzed and discussed in terms of comparisons with similar surveys of medical and dental programs. Evidence in the psychology literature was presented about the strengths and limitations of this selection tool. Eighty percent of the optometry programs that responded provided admission interviews. Concerns about interview reliability, validity, and costs precluded its use by 20% of the responding programs. Of four variables, the interview was the third most important variable in admission decisions. Unlike medical and dental programs, optometry programs frequently used a panel format; an approach which is recommended in the psychology literature. Similar to surveys of dental and medical programs, the reliability and validity of optometry admission interviews were likely reduced by insufficient interviewer training and interview structure. A need for greater program evaluation of the optometry interview process as well as dissemination of the results was indicated.

Visual recovery in a patient with Leber hereditary optic neuropathy and the 14484 mutation.

Leber hereditary optic neuropathy (LHON) is characterized by an acute, painless, sequentially bilateral reduction in vision that usually occurs in young men. It is a maternally inherited mitochondrial genetic disease. This case report details the chronology of the bilateral vision loss of a patient found to have LHON with a mutation at nucleotide site 14484. A spontaneous recovery of visual acuity and decrease in disability occurred without a corresponding improvement in color vision, contrast sensitivity, or pattern visual evoked potential (VEP's) over a period of 6 years. The abnormal pattern VEP's were one of the indicators of the neural damage to the spatial frequency channels of the visual system. The normal flash VEP's, as determined by the critical frequency of photic driving (CFPD), suggested that most of the fibers in the luminance channels were unaffected by LHON.

Admission and optometry grade comparisons among students receiving different types of admission interviews.

This retrospective study examined the interview scores, admission grades, and optometry grades of students who received one of two types of admission interviews. The INDIV-BLIND group (N = 36) represented those students who had received an individual interview (i.e., one interviewer) for which the interviewer had no access to the candidate's file. The PANEL-ACCESS group (N = 21) was made up of those students who had received a panel interview (i.e., two interviewers) for which the interviewers had access to the candidate's file. The two groups were compared using two admission grades and seven optometry grades. Both t-test and Wilcoxon Score statistical procedures were used to test the null hypothesis (H0) that there were no significant grade differences (p < 0.05) between the INDIV-BLIND and PANEL-ACCESS groups. The H0 was accepted. There were no indications that the homogeneity of grades in the two groups was a function of the admission process. When the interview scores in each group were considered, Spearman Correlation Coefficients showed that the interview scores of the PANEL-ACCESS group significantly correlated (p < 0.05) with six of the academic grades such that better scores were associated with higher grades. No such correlations were found for the INDIV-BLIND group. The results were interpreted as evidence that interviewers can be unduly influenced in their scoring of the interview by the candidate's written file. The difference in skills reflected by the interview score and the clinic grade was suggested as an important factor in accounting for the lack of correlation between these two measures.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of experimental scotoma size and shape on the binocular and monocular pattern visual evoked potential.

A small experimental, central scotoma significantly attenuates the human pattern visual evoked potential. The steady-state pattern visual evoked potential was recorded from seven visually normal adults who viewed a reversing checkerboard with 24' checks and a central scotoma that varied in size and shape. We found that square scotomas had to be at least 3 x 3 degrees to significantly (p < 0.05) attenuate the pattern visual evoked potential. Receptor density has been shown to be greater along the horizontal meridian than the vertical meridian. We hypothesized that this results in greater cortical representation of the horizontal meridian than the vertical meridian and, therefore, the pattern visual evoked potential might be significantly attenuated by a smaller rectangular scotoma oriented along the horizontal meridian than along the vertical meridian. One dimension of the rectangular scotoma was fixed at either 1 degree or 3 degrees, while the other dimension was varied from 1 degree to 8 degrees. The threshold scotoma size that significantly (p < 0.05) attenuated the pattern visual evoked potential was a horizontal scotoma subtending 1 x 4 degrees and a vertical scotoma subtending 5 x 1 degree (vertical x horizontal). Meridional differences in cortical representation were not apparent to the larger scotoma series in which the fixed dimension subtended 3 degrees (3 x 2 degrees and 2 x 3 degrees). Further analysis of the data revealed that the apparent meridional difference for the 1 degree scotoma series was a function of data variability. The determinant of the PVEP amplitude was scotoma area, not orientation. Monocular and binocular threshold scotoma sizes were the same, which could be due to the level of binocular summation demonstrated by our subjects.

Neural and psychophysical correlates of induced interocular transmission disparities.

We investigated the influences of luminance and temporal asymmetries on the pattern visually evoked potential (pVEP) as a function of stimulus contrast. Monocular and binocular baseline steady-state (ss) and transient (t) pVEP's were recorded on 10 visually normal young adults using a reversing checkerboard pattern ranging in contrast from 4 to 65%. Neutral density (ND) filters were then placed before the right eye in 0.5 ND increments (maximum 3.5 ND), as monocular and binocular pVEP's were recorded. Visual acuity, brightness sense, and the Pulfrich effect were then measured to similar luminance and temporal asymmetries. Neural and psychophysical data were compared. Monocular visual acuity and pVEP results appeared to be luminance-dependent. Brightness sense, the Pulfrich effect, and binocular pVEP amplitudes appeared to be temporarlly dependent. The binocular pVEP amplitude seemed to be less sensitive to temporal asymmetries for lower contrast targets.

Retinal adaptation effects on the patterned VEP and ERG.

The patterned visually evoked potential (pVEP) and patterned electroretinogram (pERG) after light and dark adaptation were investigated in 10 visually normal human observers. The influence of retinal preadaptation on the pVEP appeared to be dependent on the stimulus field size. With a 6 degree field size retinal adaptation effects were not apparent, but with a 12 degree field size the amplitudes of the dark-adapted steady-state pVEP (ssVEP) and transient pVEP (tVEP) were significantly larger than the light-adapted amplitudes. Similarly pERG's elicited by a 12 degree field size produced larger amplitude dark-adapted results. The implications of these findings are discussed. Monitoring the temporal changes in the pVEP subsequent to different retinal preadaptation levels proved to be inconclusive for the conditions studied.

An electrophysiological investigation of visual function in juvenile insulin-dependent diabetes mellitus.

Current diabetes research is directed at preventing secondary complications such as diabetic retinopathy (DR) that can have devastating effects on vision. Diagnosis of DR is traditionally dependent on visible alterations of retinal vasculature. However, the detection of functional disorders, likely occurring before observable changes in structure, may provide advanced warning of impending DR. We examined the neural function of the retina by electroretinograms (ERG's) and the macular-cortical pathways by visual evoked potentials (VEP's) in 30 insulin-controlled juvenile diabetics and an age-and sex-matched group of nondiabetics. The average duration of diabetes in the test group with normal retinal vasculature was 5.6 +/- 4.6 years. Results showed small but measurable differences in the amplitude and timing characteristics of retinal and cortical potentials for the test and control groups. The most surprising findings related to shorter response times for the "b" wave of the photopic ERG, larger amplitude oscillatory potentials, and larger steady-state VEP's. These may be the earliest signs of increased segmental blood flow by vascular autoregulatory mechanisms to compensate for generalized hypoxia. Longitudinal studies are required to determine the physiological significance of our findings and the prognostic value of evoked potentials in diabetes.

Clinical evaluation of ocular and visual functions in insulin-dependent juvenile diabetics.

Ocular and visual functions were evaluated in 30 insulin-dependent diabetics, aged 12 to 20 years, and 30 age- and sex-matched nondiabetics. The test and control groups were compared in terms of visual resolution, accommodative ability, color discrimination, functional retinal reserve, and afferent optic nerve function. These results were considered along with the blood-glucose level, crystalline lens, fundus appearance, level of diabetic control, and disease duration. No widespread differences in ocular or visual function were found between the test and control groups. Measures of accommodative ability, functional retinal reserve (photostress recovery time), and blood-glucose level best differentiated the two groups. This study suggests that in-office evaluation of accommodation and functional retinal reserve may be sensitive indicators of early visual functional deficits in the presence of minimal anatomical changes associated with diabetes.

Flicker haloes observed with subjective borders.

Subjective borders are known to behave quite similarly to real borders when the stimulus presents fragments of visually meaningful forms. There is less information on whether this also applies to unfamiliar stimulus elements. Thus, if a dark/bright stimulus border is presented intermittently at certain frequencies below flicker fusion, the bright border enhancement band increases greatly in width and takes on a textured appearance, resembling a halo streaming from the border. The percept is spontaneous and unlike anything experienced in real life. Preliminary observations showed that the effect occurs also at subjective borders. The extent of the halo from the border was measured for various flicker frequencies and compared with similar measurements obtained with real borders. It was found that the extent varies with frequency in an identical manner for real and virtual borders. Also, the halo was judged equal in qualitative appearance for both kinds of border. The striking similarity between virtual and real effects in this respect is best explained in terms of physiological border perception processes, possibly instigated by a cognitive mechanism.