Ambiguous Clinical Situations Research Articles

Script concordance testing in genetic counseling training: Apilot study.

Clinical reasoning is a complex skill that represents a trainee's ability to use their professional knowledge and skills to assess and solve the problems that arise in clinical practice. As an integral tenet of the genetic counseling process, clinical reasoning skills underlie many of the Practice-Based Competencies (2019) across a variety of domains. Despite the long-lasting recognition of the importance of this complex skill in the training of genetic counselors, clinical reasoning has traditionally been difficult to assess in a standardized way in healthcare education. Script concordance testing is a standardized method of assessing clinical reasoning skills in ambiguous clinical situations. The tool has been used to successfully measure the clinical reasoning skills of trainees in various healthcare training programs and has never been used in a genetic counseling training program. We conducted a pilot study to assess the utility of script concordance testing in the field of genetic counseling as an objective measure of clinical reasoning in trainees. The script concordance test was constructed for the field of genetic counseling and administered to 22 second year genetic counseling students in the Joan H. Marks Graduate Program in Human Genetics at Sarah Lawrence College. Twelve genetic counselors served on a panel to provide expert clinical reasoning responses and a scoring grid was developed using the aggregate scores method. The utility of the tool was measured using Cronbach's alpha coefficient, and scores of students and the panel were compared using Hedge's g. Results revealed statistically significant differences between the scores of panelists and students and good reliability. This study shows that script concordance testing can be used to measure clinical reasoning skills in genetic counseling trainees in a way that is reliable, standardized, and easy to use, thereby allowing programs to better assess the clinical reasoning skills of trainees prior to graduation.

Facilitators of uncertainty in decision-making in Iranian nurses: A qualitative study

Background: Many nurses are uncertain when making clinical decisions, and this can lead to burnout and professional dissatisfaction. However, no study has addressed facilitators of uncertainty in clinical decision-making among Iranian nurses. Objectives: This study aimed to explore Iranian nurses' experiences of facilitators of uncertainty in decision-making. Methods: This qualitative content analysis study was conducted from June to December 2020. Participants were 17 nurses with bachelor's or higher degrees who were purposively recruited from three hospitals affiliated with Tabriz University of Medical Sciences. Data were collected through semi-structured interviews and analyzed through a content analysis method. Results: Participants' experiences were categorized into three main categories, namely, an unconfident nurse, complex situations, and unclear guidelines and policies. Each category included three to four subcategories. Conclusion: Nurses may experience uncertainty in clinical decision-making when confronted with ambiguous clinical situations or lack sufficient decision-making skills. Nurse leaders are suggested to develop educational programs and support interventions to promote nurses' decision-making skills and help them manage ambiguous situations.

Commentary: Delphi method in ophthalmology: The guiding principles from experienced minds for ambiguous clinical situations.

Commentary: Delphi method in ophthalmology: The guiding principles from experienced minds for ambiguous clinical situations.

Negative Capability, Heuristics and Supervision

While struggling to construct the meaning of their patients’ experiences, therapists often feel confused by their patients’ communications, driving them to elicit patterns of knowledge and intuitive rules, drawn from previous experiences, and to restore a sense of control. However, what is already known might affect the unknown, biasing the meaning of patients’ communications, hence Bion's recommendation of therapists’ attunement without memory and desire. The present article describes how supervisors can enhance their supervisees’ ‘negative capability’, their tolerance of ambiguity and doubts, by illuminating specific countertransferential reactions in the form of heuristics that interrupt this capability. Heuristics, presented in the literature as potentially helpful mental devices, are examined in this article as possible disruptions to therapists’ meaning‐making processes. However, heuristics in and of themselves are not negative or pathological phenomena. They are natural and spontaneous mechanisms, capable of temporarily reducing the anxiety of supervisees faced with ambiguous clinical situations. It is suggested that understanding the meaning of these phenomena might liberate supervisees from the need to respond impulsively and facilitate internal processes of metabolizing patients’ experiences.

Using Motion Picture Films to Teach Nursing Theory in Graduate Nursing Education.

Teaching strategies that use pedagogy of inquiry and contextualization are needed to ensure that nursing students will be well prepared to manage increasingly complex patient information. The rationale for using motion pictures to teach theoretical thinking is explained, and an assignment that uses motion pictures is described. Film scene assignments facilitate learning theoretical thinking skills, reading clinical situations, and understanding how theory can be useful to problem-solve ambiguous clinical situations. Motion pictures present a text-in-motion that can be studied and analyzed in a repeatable, objective, and collaborative way.

Enhancing the Relationship Between Regulators and Their Profession.

Regulators face unique pressures to balance competing priorities related to patient safety, public accountability, and practitioners' expectations. Historically, the collegial model of self-regulation has been used as a tool for risk management, to recognize the importance of profession- and context-specific judgment in complex, ambiguous clinical situations. Increasingly, as public accountability concerns have grown dominant within regulatory bodies, this collegial model has shifted toward a more antagonistic relationship between the regulators and the regulated. Wilkie and Tzountzouris (2017) highlight one profession's journey toward embedding professionalism within regulatory practices and policies through application of a right-touch regulatory philosophy. Given the complexity of regulatory work, this shift required significant strategic and deliberative thinking. The challenges of facilitating this sort of cultural shift in the role of a regulator are significant, but so too are the potential gains associated with a more engaged relationship between regulators and their practitioners.

Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis.

To analyze the concept of ambiguity in a nursing context. Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP). Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis. Attributes of AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable. Antecedents include (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity. Consequences include ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses. Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.

Variations in prostate biopsy practice: A quantitative questionnaire-based study

The ambivalent results of recent large randomized prostate cancer studies have added a significant layer of uncertainty for clinicians and patients contemplating investigation of early disease. This uncertainty and lack of prescriptive recommendations from professional organizations has led to significant variation in practice in North America. The purpose of this study was to determine the extent of variation in biopsy recommendations by urologists and to discern factors predictive for these recommendations. An anonymous, cross-sectional, self-report questionnaire was sent to all active members of the Canadian Urological Association practicing in Ontario. The survey consisted of demographic data and 10 closed-ended questions designed to capture biopsy preferences in ambiguous clinical situations. Respondent preferences for recommending a prostate biopsy were compared to a guideline-informed study standard. Descriptive and correlative statistics were used to analyze the responses. The response rate to the survey was 74%. The responses showed considerable variability in recommendations for or against biopsy. While most of the urologists concurred with the research team's study standard recommendations, only 4 scenarios had over 80% concurrence and 1 scenario, which centered on the utility of free PSA, had only had 42% concurrence. None of the respondent's descriptors were associated with trends to recommend biopsy other than the number of biopsies performed per year (p = 0.04). This self-report survey investigating prostate biopsy thresholds identifies considerable variation in practicing urologists in Ontario. The drivers of biopsy recommendations in these relatively ambiguous clinical situations appeared to be age, suspicious rectal examinations, and total PSA.

What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear

Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients' preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and "collaborative cognition" among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes ("whole mind") and involving others in exploring, clarifying, and co-constructing patients' preferences ("shared mind"). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.

The Association Between Intolerance of Ambiguity and Decline in Medical Studentsʼ Attitudes Toward the Underserved

Little published research details the risk factors for the decline in students' attitudes toward underserved populations during medical school. The authors assessed the association between this attitude change and intolerance of ambiguity (the tendency to perceive novel or complex situations as sources of threat), since treating underserved populations often involves a high level of complexity. The University of New Mexico School of Medicine administered a survey assessing attitudes toward underserved populations at matriculation and at graduation to seven consecutive medical school classes (matriculation years 1999 to 2005). The university also administered a survey measuring tolerance of ambiguity at matriculation. Five hundred twenty-nine students were eligible to complete both surveys between 1999 and 2009. Three hundred thirteen (59%) students completed the attitude survey at matriculation and graduation. Attitude scores for a majority of students (69%) decreased from matriculation to graduation. Changes in scores ranged from +25 to -35; the average change was -4.5. Linear regression analysis showed that those who were tolerant of ambiguity (top 20% of tolerance of ambiguity scores) were significantly less likely to have declines in attitudes toward the underserved; the coefficient was 3.69 (P = .003). Other factors independently associated with maintaining high attitude scores were being female and starting medical school at age 24 or younger. Attention to, and practice with, ambiguous situations may help moderate decreases in attitudes toward underserved populations. Medical education should address the fact that physicians face much ambiguity and should offer students tools to help them respond to ambiguous clinical situations.

Graft-Versus-Host Disease or Infection: Rapid Detection of HLA Mismatch-Reactive T Cells Ex Vivo Can Facilitate Diagnosis and Guide Therapy after Allogeneic Transplantation.

Diagnosis of graft-versus-host disease (GVHD) is mainly based on clinical features and on tissue biopsies. However, clinicians and pathologists are well aware of cases, in which GVHD cannot be distinguished from infections arising from severe immunodeficiency after allogeneic stem-cell transplantation (SCT). This may pose a deep therapeutic dilemma of whether to modify immunosuppressive treatment or to use donor lymphocyte infusion (DLI) for promoting anti-microbial immunity. We observed a 68-year-old patient with myelodysplastic syndrome who developed acute GVHD grade II of skin and gut at d+16 after T-cell depleted reduced-intensity SCT (Fig. 1). GVHD was confirmed by histology and responded to prednisolone therapy. From d+90 to d+240, the patient suffered from massive diarrhea (>2L per day) and recurrent episodes of lower gastrointestinal bleeding. Histopathology analysis on gut biopsies showed a heterogeneous picture with signs of GVHD and ulcerative inflammation. In stool screening, we isolated norovirus type 2 (ELISA, PCR) between d+111 and d+229, thereby confirming the longest infection with this virus ever reported. Tapering immunosuppression did not improve diarrhea, and the patient required intensive care due to serious fluid imbalance. Because of severe lymphopenia (<100 per μL CD3 T cells), we considered DLI therapy to promote T cell reconstitution and norovirus clearance. To balance the risk for DLI-induced exacerbation of GVHD, we first analyzed peripheral blood CD8 T cells for anti-recipient reactivity ex vivo by IFN-γ ELISPOT assay. Due to the limited availability of recipient cells and a single HLA disparity between donor (B*3508) and patient (B*3503), we used HLA-deficient K562 cells transfected with mismatched (B*3503) or matched (A*0201) HLA alleles as antigen-presenting cells. Post-transplant CD8 T cells specifically recognized disparate HLA-B*3503 (Fig. 1), but not shared HLA-A*0201. Mismatch-reactive CD8 T cells were detectable at significant numbers (71/105) during the first episode of GVHD and correlated closely with the intensity of diarrhea beyond d+110. Maximum anti-HLA-B*3503 reactivity (439/105) on d+205 was in the range of IFN-γ spot production obtained in mitogen-stimulated controls. Considering this vigorous alloreactivity, we were concerned that scheduled DLI would boost GVHD rather than facilitating norovirus clearance. Therefore, we decided to omit DLI. Patient's clinical condition improved spontaneously around d+240, and diarrhea did not recur thereafter. In conclusion, we have established a new T cell assay for the rapid detection of anti-HLA mismatch reactivity using K562-HLA transfectants as substitutes for patient cells. In the meantime, we have validated this assay in two further HLA-incompatible donor-patient pairs and generated off-the-shelf K562 transfectants for more than 15 HLA alleles. Ex vivo alloreactivity toward mismatch HLA might be a surrogate marker to facilitate GVHD diagnosis and guide therapy in ambiguous clinical situations, such as the coincident viral infection described herein. [Display omitted]

How does evidence on the diagnostic accuracy of the vertebral artery test influence teaching of the test in a professional physical therapist education program?

The purpose of “Evidence in Practice” is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated. Although faculty members have always had the obligation to remain current in their teaching,1 they are now being called on to provide evidence to support classroom teaching.2 We believe evidence-based teaching leads to several positive outcomes. First, the importance of using evidence to make decisions is modeled to students. Second, students are shown that, for some topics, the evidence is contradictory or sparse. Addressing this ambiguity in the classroom also models ways to address similarly ambiguous clinical situations. Third, evidence-based teaching provides faculty with one standard for deciding what should or should not be included in a curriculum. When teaching tests and measures to physical therapist students, we believe faculty should teach not only psychomotor competency, but also the appropriate use of test information in the clinical reasoning process. In order to draw confident conclusions from a clinical test, clinicians must understand the diagnostic characteristics of that test. Faculty should present the available evidence on diagnostic accuracy—including sensitivity, specificity, positive and negative predictive values, and likelihood ratios—particularly when the test itself puts the patient at risk. In the case of vertebral artery (VA) testing, the information gained from the test must outweigh the risk to the patient. Vertebral artery testing is a traditional component of cervical spine examination for the assessment of vertebrobasilar insufficiency (VBI),3–7 a syndrome of brainstem ischemia.8 This syndrome can result from pathologies such as atherosclerosis of the subclavian, vertebral, and basilar arteries; postural hypotension; Stokes-Adams attacks; and mechanical compression from cervical spondylosis.9 It also has been attributed to cervical spine examination …

Judgment Strategies for Coping With Ambiguous Clinical Situations Encountered in Primary Family Care

This naturalistic study identifies and describes strategies for clinical problem solving in situations of uncertainty, from observations of patient/family visits in a family health center. Judgment strategies were described for four types of uncertainty: information, diagnosis, treatment, and patient response that roughly correspond to the phases of assessment, planning, implementation, and evaluation of the clinical problem-solving process. The study contributes to increased understanding of the practical (experiential) knowledge involved in clinical judgment.

Lymphoproliferative Responses to Borrelia burgdorferi in Lyme Disease

To compare lymphocyte proliferative responses to Borrelia burgdorferi in healthy controls and patients with Lyme disease. Twelve patients fulfilling case-definition criteria for Lyme disease. Twelve healthy volunteers and two newborns served as controls. Antibodies to B. burgdorferi were measured by enzyme-linked immunosorbent assay (ELISA). Proliferation of peripheral blood lymphocytes cultured for 5 days with B. burgdorferi, recall antigens, or pokeweed mitogen was measured by radioactive thymidine uptake. Lymphocytes from 11 patients with Lyme disease, 8 healthy seronegative controls, and two newborns showed elevated responses when stimulated with B. burgdorferi. When a patient and a control were studied on the same day, the patient's lymphocyte response to B. burgdorferi exceeded the control's in only 5 of 12 cases. Lymphocytes from both patients and controls responded to B. burgdorferi isolates from three different sources. Heightened lymphocyte responses to B. burgdorferi are found in patients with Lyme disease but elevated responses also frequently occur in healthy controls. At present, the interpretation of a positive lymphocyte response to B. burgdorferi would be difficult in ambiguous clinical situations.