Arthur S. Elstein

Improving Continuing Medical Education for Surgical Techniques: Applying the Lessons Learned in the First Decade of Minimal Access Surgery

ObjectiveTo examine the first decade of experience with minimal access surgery, with particular attention to issues of training surgeons already in practice, and to provide a set of recommendations to improve technical training for surgeons in practice. Summary Background DataConcerns about the adequacy of training in new techniques for practicing surgeons began almost immediately after the introduction of laparoscopic cholecystectomy. The concern was restated throughout the following decade with seemingly little progress in addressing it. MethodsA preliminary search of the medical literature revealed no systematic review of continuing medical education for technical skills. The search was broadened to include educational, medical, and psychological databases in four general areas: surgical training curricula, continuing medical education, learning curve, and general motor skills theory. ResultsThe introduction and the evolution of minimal access surgery have helped to focus attention on technical skills training. The experience in the first decade has provided evidence that surgical skills training shares many characteristics with general motor skills training, thus suggesting several ways of improving continuing medical education in technical skills. ConclusionsThe educational effectiveness of the short-course type of continuing medical education currently offered for training in new surgical techniques should be established, or this type of training should be abandoned. At present, short courses offer a means of introducing technical innovation, and so recommendations for improving the educational effectiveness of the short-course format are offered. These recommendations are followed by suggestions for research.

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

1: Studies of Problem Solving, Judgment, and Decision Making: Implications for Educational Research:

Bruner (1971) quotes an aphorism he attributes to the English Platonist Weldon. It is apt as a prolegomenon to this chapter: . . . there are three kinds of things in the world: there are troubles which we do not know quite how to handle; then there are puzzles with their clear conditions and unique solutions, marvelously elegant; and then there are problems-and these we invent by finding an appropriate puzzle form to impose upon a trouble (p. 104). Educational researchers attack problems for which convenient puzzle forms exist. As evidence for this assertion, witness the continuing preoccupation with studies of paired-associate learning, adjunct questions, learning hierarchies, and social-class differences in intelligence and achievement. Research typically slights the problem of how teachers think about their pupils and instructional problems; it concentrates instead on how teachers act or perform in the classroom. It is our hope that by providing a number of puzzle forms for the study of individual judgment and problem solving, we can make it possible for more of our colleagues to pursue educational research in these areas. In this chapter we shall review representative studies and theoretical proposals on thinking, human judgment, and decision making. Since judgment, decision making, and problem solving are used in so many ways, the scope of our treatment will be outlined here. First, the focus will be mostly

Human Factors in Clinical Judgment: Discussion of Scriven’s ‘Clinical Judgment’

It would be quite impossible to comment in detail on each of the main points in Scriven’s wide-ranging paper. Much of it is concerned with the issue of clinical versus statistical prediction and with the implications of the well replicated research finding that clinical judgments can be reproduced or even improved upon by simple statistical formulas derived from a representative sample of prior judgments [11]. This appears to be a puzzling, contra-intuitive, controversial research finding. For surely its implications have been only slowly incorporated in clinical practice, and have perhaps been more resisted and avoided than attended to. This discussion, therefore, will focus on one major question: Why do simple formulas for judgment so consistently equal or exceed the accuracy of human inference? I shall answer this question in two ways: first, by offering a critique of human judgment from an information-processing perspective, and second, by critically examining the research model that produced this finding My concern will be, then, with the psychological processes of clinical judgment and with ascertaining what research on clinical judgment has actually studied. The overall thrust of the discussion will be to agree with the main line of Scriven’s argument, while pointing out that there is still an “on the other hand”.

Problem Solving: Applications of Research to Undergraduate Instruction and Evaluation.

Problem Solving: Applications of Research to Undergraduate Instruction and EvaluationAbstract The formal reasoning strategy used in medical diagnostic problem solving can be conceptualised as composed of four more elementary processes — cue acquisition, hypothesis generation, cue interpretation and hypothesis evaluation. These processes are closely linked to the clinicians store of medical knowledge. The acquisition, retention and recall of content cannot ensure its effective application, yet training in problem‐solving skills with inadequate attention to factual content will not be effective either. Two educational programmes are described which aim to increase the effective linking of clinical strategy and clinical memory in undergraduate medical students. Clinical problem‐solving sessions use simulated cases to provide experience in blending clinical knowledge and problem‐solving strategies. Problem‐solving examinations offer the opportunity for students to display the reasoning and planning behind th...

Organizational and psychological problems in developing community mental health services: A case study

Abstract Organizational and psychological problems encountered in reorganizing a research-oriented mental hospital with a highly selected clientele and a predominantly psychoanalytic ideology into a community mental health center are presented in this case study. A period of social crisis marked by suicides and suicide attempts occurred. A variety of definitions of the situation and their relationship to occupational status are presented in an effort to reconstruct the world of the mental hospital as it was understood by different groups of professionals. Sources of conflict and modes of adaptation are identified. Reasons for advancing and resisting change are discussed.