Review of Introduction to psychodynamics and
                                                psychotherapy: Clinical vignettes and
                                                interpretations.

BackgroundAntibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians’ antibiotic prescribing.MethodsWe conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework.ResultsClinicians’ antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented ‘erring on the side of caution’ as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences (‘being burnt’) which motivated prescribing ‘just in case’ of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms.ConclusionEfforts to improve antibiotic stewardship should consider clinicians’ desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians’ fears of not prescribing or of using narrower-spectrum antibiotics.

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The effect of prior experience on diagnostic reasoning: exploration of availability bias

Diagnosis ◽

10.1515/dx-2019-0091 ◽

2020 ◽

Vol 7 (3) ◽

pp. 265-272

Author(s):

Sandra Monteiro ◽

Jonathan Sherbino ◽

Jonathan S. Ilgen ◽

Emily M. Hayden ◽

Elizabeth Howey ◽

...

Keyword(s):

Medical Students ◽

Clinical Features ◽

Patient Characteristics ◽

Diagnostic Error ◽

Diagnostic Reasoning ◽

Error Rates ◽

Prior Exposure ◽

Clinical Vignettes ◽

Experience Levels ◽

Similar Patient

AbstractObjectivesDiagnostic reasoning has been shown to be influenced by a prior similar patient case. However, it is unclear whether this process influences diagnostic error rates or whether clinicians at all experience levels are equally susceptible. The present study measured the influence of specific prior exposure and experience level on diagnostic accuracy.MethodsTo create the experience of prior exposure, participants (pre-clerkship medical students, emergency medicine residents, and faculty) first verified diagnoses of clinical vignettes. The influence of prior exposures was measured using equiprobable clinical vignettes; indicating two diagnoses. Participants diagnosed equiprobable cases that were: 1) matched to exposure cases (in one of three conditions: a) similar patient features, similar clinical features; b) dissimilar patient features, similar clinical features; c) similar patient features, dissimilar clinical features), or 2) not matched to any prior case (d) no exposure). A diagnosis consistent with a matched exposure case was scored correct. Cases with no prior exposure had no matched cases, hence validated the equiprobable design.ResultsDiagnosis A represented 47% of responses in condition d, but there was no influence of specific similarity of patient characteristics for Diagnosis A, F(3,712)=7.28, p=0.28 or Diagnosis B, F(3,712)=4.87, p=0.19. When re-scored based on matching both equiprobable diagnoses, accuracy was high, but favored faculty (n=40) 98%, and residents (n=39) 98% over medical students (n=32) 85%, F(2,712)=35.6, p<0.0001. Accuracy for medical students was 84, 87, 94, and 73% for conditions a–d, respectively, interaction F(2,712)=3.55, p<0.002.ConclusionsThe differential diagnosis of pre-clerkship medical students improved with prior exposure, but this was unrelated to specific case or patient features. The accuracy of medical residents and staff was not influenced by prior exposure.

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How accurate are digital symptom assessment apps for suggesting conditions and urgency advice? A clinical vignettes comparison to GPs

BMJ Open ◽

10.1136/bmjopen-2020-040269 ◽

2020 ◽

Vol 10 (12) ◽

pp. e040269

Author(s):

Stephen Gilbert ◽

Alicia Mehl ◽

Adel Baluch ◽

Caoimhe Cawley ◽

Jean Challiner ◽

...

Keyword(s):

Gold Standard ◽

Symptom Assessment ◽

Primary Diagnosis ◽

Safety Performance ◽

Digital Tool ◽

Alphabetical Order ◽

Clinical Vignettes ◽

Gps Buoy ◽

Coverage Accuracy ◽

Young Old

ObjectivesTo compare breadth of condition coverage, accuracy of suggested conditions and appropriateness of urgency advice of eight popular symptom assessment apps.DesignVignettes study.Setting200 primary care vignettes.Intervention/comparatorFor eight apps and seven general practitioners (GPs): breadth of coverage and condition-suggestion and urgency advice accuracy measured against the vignettes’ gold-standard.Primary outcome measures(1) Proportion of conditions ‘covered’ by an app, that is, not excluded because the user was too young/old or pregnant, or not modelled; (2) proportion of vignettes with the correct primary diagnosis among the top 3 conditions suggested; (3) proportion of ‘safe’ urgency advice (ie, at gold standard level, more conservative, or no more than one level less conservative).ResultsCondition-suggestion coverage was highly variable, with some apps not offering a suggestion for many users: in alphabetical order, Ada: 99.0%; Babylon: 51.5%; Buoy: 88.5%; K Health: 74.5%; Mediktor: 80.5%; Symptomate: 61.5%; Your.MD: 64.5%; WebMD: 93.0%. Top-3 suggestion accuracy was GPs (average): 82.1%±5.2%; Ada: 70.5%; Babylon: 32.0%; Buoy: 43.0%; K Health: 36.0%; Mediktor: 36.0%; Symptomate: 27.5%; WebMD: 35.5%; Your.MD: 23.5%. Some apps excluded certain user demographics or conditions and their performance was generally greater with the exclusion of corresponding vignettes. For safe urgency advice, tested GPs had an average of 97.0%±2.5%. For the vignettes with advice provided, only three apps had safety performance within 1 SD of the GPs—Ada: 97.0%; Babylon: 95.1%; Symptomate: 97.8%. One app had a safety performance within 2 SDs of GPs—Your.MD: 92.6%. Three apps had a safety performance outside 2 SDs of GPs—Buoy: 80.0% (p<0.001); K Health: 81.3% (p<0.001); Mediktor: 87.3% (p=1.3×10-3).ConclusionsThe utility of digital symptom assessment apps relies on coverage, accuracy and safety. While no digital tool outperformed GPs, some came close, and the nature of iterative improvements to software offers scalable improvements to care.

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The role of secrets in the invention or reinvention of families

Couple and Family Psychoanalysis ◽

10.33212/cfp.v11n2.2021.129 ◽

2021 ◽

Vol 11 (2) ◽

pp. 129-141

Author(s):

Susana Muszkat ◽

Monica Vorchheimer

Keyword(s):

Psychological Symptoms ◽

Clinical Vignettes ◽

Theoretical Approaches ◽

The Family

The authors propose that there are secrets in all families and discuss the link effects they produce as they are either transmitted transgenerationally or withheld from members of the family they actually concern. Secrets have determinant influences on the link configuration of families, on its dynamics, and, even, on its symptomatic formations. Often, an intentional or accidental revelation of secrets that were previously kept buried produce an explosive commotion within a family. Unmourned memories shape our destinies in disguised manners, and manifest themselves not as revelations of such secrets but as important psychological symptoms that pervade across generations. Different theoretical approaches are discussed and two clinical vignettes exemplify the text.

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ENTRE ENCUENTRO Y DESENCUENTRO: TEMPORALIDAD EN TERAPIA DE PAREJA

De Familias y Terapias ◽

10.29260/dfyt.2020.49e ◽

2020 ◽

Vol 1 (49) ◽

pp. 69-89

Author(s):

sofía De la Puerta ◽

Carolina Correa

Keyword(s):

Clinical Practice ◽

Systemic Therapy ◽

Couple Therapy ◽

Clinical Case ◽

Subjective Time ◽

Present Moment ◽

Clinical Process ◽

Heterosexual Couple ◽

Clinical Vignettes ◽

One Year

The objective of this work is to understand a clinical process of systemic orientation from the perspective of subjective temporality. The work is based on the theory of subjective time and considers its historical and sociocultural dimension, reviewing its main theoretical constructs that will understand couple relationships and therapeutic processes. A clinical case was analyzed a from the perspective of subjective temporality, based on the main antecedents of the case and using clinical vignettes. Participants were a 36- and 37-year-old heterosexual couple who participated in a couple therapy with two therapists trained in systemic therapy for approximately one year. The sessions were videotaped and analyzed through the theory of subjective temporality. The analysis of the subjective temporality constitutes a contribution to the clinical practice, since it allows to understand and to develop an approach centered in the present moment and that allows analyzing the synchrony and encounter of the members of the system.

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Coding for Pediatrics 2015

10.1542/9781581109009 ◽

2014 ◽

Author(s):

Keyword(s):

American Academy ◽

Nurse Practitioners ◽

Current Procedural Terminology ◽

Clinical Vignettes ◽

American Academy Of Pediatrics ◽

Icd 10 ◽

The Many

Published annually and currently in its 20th edition, Coding for Pediatrics is the signature publication in a comprehensive suite of coding products offered by the American Academy of Pediatrics (AAP). This AAP exclusive complements standard coding manuals with pediatric-specific documentation and billing solutions for pediatricians, nurse practitioners, administration staff, and pediatric coders. This year’s edition has been fully updated and revised to include all changes to the 2015 Current Procedural Terminology (CPT®) codes, complete with accompanying guidelines for their application. The numerous clinical vignettes and examples featured in the book, as well as the many coding pearls included throughout, have also been fully revised and revisited. On October 1, 2015 all HIPAA covered entities will transition to the ICD-10-CM. Coding for Pediatrics provides guidance on this future transition including important documentation elements to support code selection in ICD-10-CM. Numerous helpful tips are included throughout the book and highlight the ICD-10-CM code set with “Transitioning to 10” boxes. Other updates to this edition include

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