Putting the puzzle together: the role of ‘problem definition’ in complex clinical judgement

Cristancho, Sayra; Lingard, Lorelei; Forbes, Thomas L.; Ott, Michael; Novick, Richard J.

doi:10.1111/medu.13210

Cited by 31 publications

(22 citation statements)

References 18 publications

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“…when?). This allows avoiding compromises, thinking backward and instead appropriately (re)defining a problem (Cristancho et al, 2017). For the sake of illustration, such a timeline is presented in Figure 2 of the Supplementary Methods 1 from the work by Hawrylycz et al (2012).…”

Section: Discussionmentioning

confidence: 99%

A Survey of Methods for 3D Histology Reconstruction

Pichat

Iglesias

Yousry³

et al. 2018

Medical Image Analysis

165

179

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Histology permits the observation of otherwise invisible structures of the internal topography of a specimen. Although it enables the investigation of tissues at a cellular level, it is invasive and breaks topology due to cutting. Three-dimensional (3D) reconstruction was thus introduced to overcome the limitations of single-section studies in a dimensional scope. 3D reconstruction finds its roots in embryology, where it enabled the visualisation of spatial relationships of developing systems and organs, and extended to biomedicine, where the observation of individual, stained sections provided only partial understanding of normal and abnormal tissues. However, despite bringing visual awareness, recovering realistic reconstructions is elusive without prior knowledge about the tissue shape. 3D medical imaging made such structural ground truths available. In addition, combining non-invasive imaging with histology unveiled invaluable opportunities to relate macroscopic information to the underlying microscopic properties of tissues through the establishment of spatial correspondences; image registration is one technique that permits the automation of such a process and we describe reconstruction methods that rely on it. It is thereby possible to recover the original topology of histology and lost relationships, gain insight into what affects the signals used to construct medical images (and characterise them), or build high resolution anatomical atlases. This paper reviews almost three decades of methods for 3D histology reconstruction from serial sections, used in the study of many different types of tissue. We first summarise the process that produces digitised sections from a tissue specimen in order to understand the peculiarity of the data, the associated artefacts and some possible ways to minimise them. We then describe methods for 3D histology reconstruction with and without the help of 3D medical imaging, along with methods of validation and some applications. We finally attempt to identify the trends and challenges that the field is facing, many of which are derived from the cross-disciplinary nature of the problem as it involves the collaboration between physicists, histolopathologists, computer scientists and physicians.

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Section: Discussionmentioning

confidence: 99%

A Survey of Methods for 3D Histology Reconstruction

Pichat

Iglesias

Yousry³

et al. 2018

Medical Image Analysis

165

179

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“…4,5 Medical educators have reframed training to spotlight the breadth of skills physicians require to identify and effectively respond to these complexities; frameworks now emphasise the critical roles that communication, collaboration and decision making play in care and patient outcomes. 4,5,14,15 For instance, because of its focus on promoting health, reducing disparities and responsibly allocating resources, the CanMEDS framework recognises health advocacy as one of seven intrinsic physician roles. 16,17 There are various approaches to advocacy that may occur at the level of the individual patient, the community or the system.…”

Section: Introductionmentioning

confidence: 99%

Navigating complexity in team‐based clinical settings

et al. 2018

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Context Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio‐relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. Methods Constructivist grounded theory informed data collection and analysis; during semi‐structured interviews, we used rich pictures to elicit team members’ perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. Results Routine care became complex when the prognosis was unknown, when treatment was either non‐existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants’ training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. Conclusions Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non‐physician team members in advocacy training.

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“…A gallery walk is a technique that stimulates active interaction with and discussions about the meaning of the drawings. 37 During the gallery walk, all 15 drawings were displayed in a room. All members of the research team participated and walked around the room engaging themselves with the drawings.…”

Section: Discussionmentioning

confidence: 99%

“…In the fourth session, we performed a gallery walk. A gallery walk is a technique that stimulates active interaction with and discussions about the meaning of the drawings . During the gallery walk, all 15 drawings were displayed in a room.…”

Section: Methodsmentioning

confidence: 99%

Trainee‐environment interactions that stimulate motivation: A rich pictures study

et al. 2019

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Context Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees’ aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees’ motivation and how they are intertwined. Methods We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results. Results Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees’ motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus. Conclusions Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

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Putting the puzzle together: the role of ‘problem definition’ in complex clinical judgement

Cited by 31 publications

References 18 publications

A Survey of Methods for 3D Histology Reconstruction

A Survey of Methods for 3D Histology Reconstruction

Navigating complexity in team‐based clinical settings

Trainee‐environment interactions that stimulate motivation: A rich pictures study

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