ABSTRACT Study objectives The objectives of this study were to elicit and document descriptions of Emergency Department (ED) physician expertise, to characterize cognitive differences between novice and expert physicians, and to identify areas where novices’ skill and knowledge gaps are most pronounced. The nature of the differences between novices and experts need to be explored in order to develop effective instructional modalities that accelerate the learning curve of inexperienced physicians who work in high complexity environments.   Methods We interviewed novice emergency medicine physicians (first-year residents) and attending physicians with significant expertise working in an academic level-one trauma center in Southern California. Using Cognitive Task Analysis (CTA), we employed task diagrams to capture non-routine critical incidents that required the use of complex cognitive skills. Time-lines were constructed to develop a detailed understanding of challenging incidents and the decisions involved as the incident unfolded, followed by progressive deepening to tease out situation specific cues, knowledge, and information that experts and novices used. A thematic analysis of the interview transcripts was conducted to identify key categories. Using classification techniques for data reduction, we identified a smaller set of key themes, which comprised the core findings of the study.   Results Five interns and six attending physicians participated in the interviews. Novice physicians reported having difficulties representing the patient’s story to attendings and other health care providers. Over-relying on objective data, novice physicians use linear thinking to move to diagnosis quickly and are likely to discount and explain away data that do not “fit” the frame. Experienced physicians draw on previous expertise to recognize cues and patterns while leaving room for altering or even changing their initial diagnosis. While experts maintain high levels of spatial, temporal, and organizational systems awareness when overseeing treatment modalities of multiple patients, novices have difficulty seeing and maintaining the “big picture.” Conclusion Novice physicians employ sense-making styles that differ from those of experts. Training novices to respond to the high cognitive demand of complex environments early on in their careers requires instructional modalities that not only increase their knowledge base, but accelerate the integration of knowledge and practice. Simulation and custom designed avatar mediated virtual worlds are a promising new technology that may facilitate such training. Future research should expand on the results of this study using a larger sample size and conducting interviews at multiple sites to increase generalizability.  

Abstract: An improved technique for histologic sectioning of hard tissues is described. Thin sections (5 to 15 microns) of undecalcified tissues such as bones with ceramic and metallic implants as well as teeth with enamel and fillings can be produced. Implant-tissue and hard tissue-soft tissue interfaces are well preserved. Because of the development of equipment and materials designed specifically for this technique, consistently good results are obtained. Most stains used in the paraffin technique may also be used in these sections.

Abstract:Despite the technical sophistication of modern medicine errors cannot be avoided. As errors are situated in the complexity and dynamicity that characterize healthcare environments they are difficult to define. A conceptual framework of medical error needs to account for the reality of medical work and the nature of error as a language-mediated social and legal construct. We identify four aspects that serve as a distinct framework: the notion of intent, the etiology of medical error and its multi-factorial flow, peer-reviewed contexts, and outcomes that may or may not result in harm to patients. The former assume moral quality and become concerns of justice. Specifically, a restorative justice approach supports the disclosure of errors to patients and addresses their physical, mental, spiritual, and social effects. The result of this contextually grounded, outcome-oriented model and accompanying definition of medical error provides practical guidance for hospital policies on dealing with medical error issues.  

Keywords: Medical error, ethics, restorative justice, conceptual model, healthcare, wholeness. 

   Abstract: A cross-sectional descriptive study was done using the Acculturation Rating scale of Arab Americans-II, and the Health Promotion and Lifestyle Profile II to assess the relationship between acculturation and health promotion practices among Arab Americans. Findings showed that attraction to American culture was the most important predictor of physical activity; whereas attraction to Arabic culture was the most important predictor of stress management and nutritional practices. Results suggest that, when demographics are controlled, acculturation predicts various health promotion practices in different patterns among members of this group. These findings contribute to a better understanding of acculturation’s influence on immigrants’ health promotion practices.

Key Words: Acculturation, Health-promotion practices, Arab Americans, HPLP II.

Abstract: Technological advances in diabetes management include continuous subcutaneous insulin infusion, or "pump therapy." This paper describes an educational intervention aimed at familiarizing nursing personnel with insulin pump therapy at a large teaching hospital. Teaching points included appropriate patient selection, principles of insulin therapy, and safe insulin pump operation. A pre-test and two post-tests measured knowledge and confidence. Overall, results indicated that the program significantly increased knowledge and confidence among nurses for managing pump therapy.