The development of clinical thinking in trainee physicians: the educator perspective.

BACKGROUND: An important element of effective clinical practice is the way physicians think when they encounter a clinical situation, with a significant number of trainee physicians challenged by translating their learning into professional practice in the clinical setting. This research explores the perceptions of educators about how trainee physicians develop their clinical thinking in clinical settings. It considers what educators and their colleagues did to help, as well as the nature of the context in which they worked. METHOD: A qualitative approach was used in this study with in depth interviews carried out with educators as key informants. Rich data derived from 15 interview transcripts were analysed thematically in a rigorous and iterative process. RESULTS: Three broad and overlapping themes were identified: working in an educationally minded culture; proximity of the educator to the trainee physician; and trajectory of the trainee physician. The departments in which these educators worked emphasised the importance for the education of trainee physicians. All members of the team were responsible for education of the team, and all members, particularly senior nurses, were able to give feedback upon the trainee physicians' progress. Educators described working side by side with their trainee physician and frequently being in close proximity to them which means that the educator was both easily accessible and spent more time with their trainee physicians. They described a trajectory of the trainee physicians through the placement with close monitoring and informal assessment throughout. CONCLUSION: Recommendations are made as to how trainee physicians can be supported to develop their clinical thinking. Educators and managers can analyse their own and their department's practice and select the recommendations relevant to their local circumstances in order to make change. This study adds the educator perspective to a body of literature about the importance of context and supportive learning environments. As such the discussion is applicable to the education of other health professionals.

How Do Contexts Affect Physicians' Clinical Reasoning? A Narrative Review.

This article was migrated. The article was marked as recommended. Background Research about clinical reasoning has tended to focus on the individual, assessing their ability to perform clinical reasoning tasks. However, recent studies have noted that clinical reasoning varies with the clinical context. Objectives The purpose of this narrative review is to examine how the context can affect physicians clinical reasoning skills. Methods A narrative literature review was conducted by searching PubMed, PsycINFO and Embase via Ovid using the search terms clinical OR critical AND thinking OR judgement OR reasoning. Of 22,296 results found, 25 studies were found to be relevant to our review. Results Most studies focused on diagnostic skills. Contexts affecting clinical reasoning fell into three broad categories: patient, physician and environmental (the physical and social setting) factors. Patient contexts researched included factors both personal to the patient and their physical disease manifestations. Physician contexts included experience, age, exposure to similar diagnoses, incorrect diagnostic suggestion, emotions, and the use of reflection and checklists. Environmental contexts included time pressure, unfamiliarity with surroundings, dealing with uncertainty and high-stakes outcomes. The effect of applying more than one contextual factor increasing cognitive load, was explored. Conclusion This original review suggests that the context can affect a physician's clinical reasoning abilities. This review identifies areas for continued research, including which contexts have a negative or positive impact, and the effect of multiple contexts (cognitive loading) on clinical reasoning. Further empirical research is needed to investigate these areas in more depth and to establish how far these benefits have an impact in practice.

General practice tasters for foundation doctors.

BACKGROUND: General practice (GP) is currently not viewed positively as a career choice, compared with other specialties, with GP training programmes struggling to fill posts. Opportunities to change this mindset in the early years of training are limited. Trainees may find themselves applying for entry into GP specialty training just 3-4 months after completing Foundation Year 1 (FY1), yet there are few GP attachments during FY1 that can provide experience of primary care and positively inform career choice. CONTEXT: To help ameliorate the current crisis in GP, recruitment and retention initiatives are needed to provide relevant experience of GP early in medical careers so that more doctors can make an informed decision to choose GP as a career. INNOVATION: FY1 doctors have been given the opportunity to shadow final-year GP specialty trainees (GPST3) in clinical practice (for between 3 and 5 days). The voluntary scheme has run successfully since 2014. This paper describes the taster programme and its evaluation. The programme has been positively received by both FY1s and GPST3 mentors. The GPST3s are enthusiastic about GP, which appeared to 'rub off' on the FY1s. FY1s find it helpful to have a trainee's perspective, gaining an overview of what to expect, including the opportunities available to them. General practice is currently not viewed positively as a career choice IMPLICATIONS: Using GPST3 trainees as mentors for FY1 doctors is educational for both groups and can have a positive impact on GP recruitment. The taster demonstrated how varied GP is, and challenged some negative perceptions of primary care. GPST3s gained confidence in their knowledge about GP and greater insight into educational roles.

Ideas and enhancements related to mobile applications to support type 1 diabetes.

BACKGROUND: Mobile devices have become increasingly important to young people who now use them to access a wide variety of health-related information. Research and policy related to the integration of health information and support with this technology do not effectively consider the viewpoint of a younger patient. Views of young people with type 1 diabetes are vital in developing quality services and improving their own health-related quality of life (HRQOL), yet research on their lifestyle and use of Web and mobile technology to support their condition and in non-health-related areas is sparse. OBJECTIVE: To develop insight into young people with type 1 diabetes and their current use of Web and mobile technology and its potential impact on HRQOL. This can be achieved by constructing an in-depth picture of their day-to-day experiences from qualitative interviewing and exploring how they make use of technology in their lives and in relation to their condition and treatment. The goal was then to build something to help them, using the researcher's technical expertise and seeking users' opinions during the design and build, utilizing sociotechnical design principles. METHODS: Data were collected by semistructured, in-depth qualitative interviews (N=9) of young people with type 1 diabetes aged 18-21. Interviews were transcribed and loaded onto NVivo for theme identification. Data analysis was undertaken during initial interviews (n=4) to locate potential ideas and enhancements for technical development. Latter interviews (n=5) assisted in the iterative sociotechnical design process of the development and provided additional developmental ideas. RESULTS: Six themes were identified providing an understanding of how participants lived with and experienced their condition and how they used technology. Four technological suggestions for improvement were taken forward for prototyping. One prototype was developed as a clinically approved app. A number of ideas for new mobile apps and enhancements to currently existing apps that did not satisfactorily cater to this age group's requirements for use in terms of design and functionality were suggested by interviewees but were not prototyped. CONCLUSIONS: This paper outlines the nonprototyped suggestions from interviewees and argues that young people with type 1 diabetes have a key role to play in the design and implementation of new technology to support them and improve HRQOL. It is vital to include and reflect on their suggestions as they have a radically different view of technology than either their parents or practitioners. We need to consider the relationship to technology that young people with type 1 diabetes have, and then reflect on how this might make a difference to them and when it might not be a suitable mechanism to use.

Nurse-led triage of acute medical admissions: accurate and time-efficient.

In many hospitals a variety of triage systems are used by senior medical staff to identify likely length of stay (LOS) of acute medical admissions and thus facilitate a streamlined admission under either acute medicine or general internal medicine (GIM). The authors evaluated if senior nursing staff on the medical assessment unit could triage patients depending on their predicted LOS as accurately as consultant acute physicians. Each of 193 medical admissions were independently triaged by both groups to either acute medicine (<48 hours) or GIM (>48 hours) depending on predicted LOS. The accuracy of patient triage was identical for senior nursing staff and consultants (80.8% vs 81.9%), when 95% confidence intervals are taken into account. Nursing staff triaged patients a mean of 8.5 hours earlier than consultants. This study demonstrates that triage of acute medical admissions is a practical extension of the senior nursing role and has been successfully implemented, with accuracy of nursing triage (83.5%) being maintained in a repeat study 6 months later.