The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions

Bowen, Leah E; Shaw, Adrienne; Lyttle, Mark D; Purdy, Sarah

doi:10.1136/emermed-2015-205211

Cited by 12 publications

(17 citation statements)

References 19 publications

(20 reference statements)

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“…Teachers responded intuitively to meet the individual needs of the child. Intuition is an important part of professional decision-making which arises from an accumulation of experience [ 37 ]. Teachers described using strategies that were consistent with evidence-based management approaches for CFS/ME and chronic health conditions more generally.…”

Section: Discussionmentioning

confidence: 99%

“it’s a medical condition … you need to support as much as possible”: a qualitative analysis of teachers’ experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

2021

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Background An increasing number of children with complex health needs are being educated in mainstream classes. CFS/ME is a complex and disabling condition, and there is little guidance on how primary school teachers can support younger children with this condition. To improve care, it is important to understand what these children need in the school setting, and the barriers and facilitators to teachers providing this support. The aims for this qualitative study were to explore teachers’ views about CFS/ME, their experiences of supporting a pupil with CFS/ME and their perspectives on the barriers and facilitators to providing support. Methods We recruited families from an NHS specialist paediatric CFS/ME service and families were eligible if the child was aged between 5 and 11 years and had a diagnosis of CFS/ME. We gained written consent/assent from families to invite the child’s teacher to participate in a qualitative interview. We contacted these teachers, gained written consent and then carried out semi-structured qualitative interviews. Interviews were audio-recorded, transcribed, anonymised and analysed thematically. Interviews took place between July 2018 and December 2018. Results We interviewed 11 teachers; their pupil’s age ranged from 5 to 11 years and school attendance ranged from 0 to 80%. Theme 1: Most teachers provided rich descriptions of their pupil’s CFS/ME; they consistently described cognitive dysfunction and significant fatigue, but beyond this the symptoms varied from one account to the next (from mobility problems, to aches and pains, digestive problems, headaches, nausea and hypersensitivity). These teachers noted the ripple effects on their pupil’s social, emotional and academic functioning. Two of the eleven teachers said that they did not observe symptoms of CFS/ME, expressing a degree of scepticism about the diagnosis. Theme 2: Teachers described a close relationship with their pupil. They said they understood the individual needs of the child and portrayed positive and proactive attitudes towards providing support. The type of support provided included facilitating rest breaks and limiting strenuous activities; using practical strategies to address cognitive, physical, social and emotional difficulties; maintaining a connection with the child during their absences from school; and encouraging the child to talk about their health and wellbeing. Teachers noted that receiving formal confirmation of the child’s diagnosis enabled them to put this support in place. Theme 3: The adaptations they described were often intuitive, rather than being based on a knowledge of CFS/ME. Teachers wanted more resources to increase their understanding of the condition and its management. Conclusions Primary school teachers want to provide effective support for children with CFS/ME. Clinical services should consider working in collaboration with teachers to equip them with evidence-based strategies for CFS/ME management in the primary school setting.

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Section: Discussionmentioning

confidence: 99%

“it’s a medical condition … you need to support as much as possible”: a qualitative analysis of teachers’ experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

2021

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“…Increasing levels of tacit knowledge seem to promote intuitive judgements and data-driven rules of thumb. 7–10 …”

Section: Introductionmentioning

confidence: 99%

Clinicians’ heuristic assessments of radiographs compared with Kellgren-Lawrence and Ahlbäck ordinal grading: an exploratory study of knee radiographs using paired comparisons

et al. 2021

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ObjectivesOrdinal scales provide means for communicating the severity of a condition, but they are affected by cognitive biases, they introduce statistical problems and they sacrifice resolution. Clinicians discern more details than contained in scales, for example, when assessing radiographs, but clinicians’ distinctions are often based on experience-based rules of thumb, that is, heuristics. The objectives of this study are to compare clinicians’ heuristic assessments to ordinal grading, to identify case elements that influence clinicians’ judgements and to present a method for quantifying heuristic assessments.DesignClinicians were presented with 17 207 random pairs from a set of 1087 knee radiographs. For each pair, the radiograph with more severe osteoarthritis was selected. The Bradley-Terry model was used to calculate an osteoarthritis strength parameter for each radiograph. Similarly, strength parameters were determined for 12 morphological features with five additional features being considered either present or absent. All radiographs were also graded according to conventional ordinal systems (Kellgren-Lawrence and Ahlbäck). Relations between clinicians’ judgements and (1) the heuristics-based osteoarthritis strength, (2) conventional ordinal systems and (3) morphological features were investigated.ResultsReceiver operating characteristic analysis showed that the Bradley-Terry model provided a good description of clinicians’ assessments (area under the curve (AUC)=0.97, 95% CI 0.968 to 0.972). Morphological features (AUC=0.90, 95% CI 0.900 to 0.908) provided a superior description of clinicians’ choices compared with conventional ordinal systems (AUC=0.88, 95% CI 0.878 to 0.887 and AUC=0.80, 95% CI 0.796 to 0.809) for Ahlbäck and Kellgren-Lawrence, respectively). The features most strongly associated with osteoarthritis strength were medial joint space width, flattening of the medial femoral and tibial condyles, medial osteophytes and alignment.ConclusionsHeuristics-based assessments give a better distinction than conventional grading systems of knee osteoarthritis. The example presents a general approach to evaluate which features are part of experts’ heuristics. The data suggest that experts discern more details than included in conventional ordinal grading systems. Quantitative heuristic assessments may replace ordinal scales.

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“…It should be noted, however, that in creating these guidelines, when the evidence for the guidance is lacking, consensus is employed. In addition, guidelines are intended to be assistive, rather than directive, and therefore clinicians often operate outside the guidance in line with their clinical experience, e.g., it has been shown that junior doctors are more likely to use guidelines rigidly than more senior doctors, who tend to go on clinical intuition [ 12 ]. In practice, chest radiographs are performed frequently for suspected pneumonia in children [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Guidelines for the use of chest radiographs in community-acquired pneumonia in children and adolescents

et al. 2017

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National guidance from the United Kingdom and the United States on community-acquired pneumonia in children states that chest radiographs are not recommended routinely in uncomplicated cases. The main reason in the ambulatory setting is that there is no evidence of a substantial impact on clinical outcomes. However clinical practice and adherence to guidance is multifactorial and includes the clinical context (developed vs. developing world), the confidence of the attending physician, the changing incidence of complications (according to the success of immunisation programs), the availability of alternative imaging (and its relationship to perceived risks of radiation) and the reliability of the interpretation of imaging. In practice, chest radiographs are performed frequently for suspected pneumonia in children. Time pressures facing clinicians at the front line, difficulties in distinguishing which children require admission, restricted bed numbers for admissions, imaging-resource limitations, perceptions regarding risk from procedures, novel imaging modalities and the probability of other causes for the child’s presentation all need to be factored into a guideline. Other drivers that often weigh in, depending on the setting, include cost-effectiveness and the fear of litigation. Not all guidelines designed for the developed world can therefore be applied to the developing world, and practice guidelines require regular review in the context of new information. In addition, radiologists must improve radiographic diagnosis of pneumonia, reach consensus on the interpretive terminology that clarifies their confidence regarding the presence of pneumonia and act to replace one imaging technique with another whenever there is proof of improved accuracy or reliability.

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The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions

Cited by 12 publications

References 19 publications

“it’s a medical condition … you need to support as much as possible”: a qualitative analysis of teachers’ experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

“it’s a medical condition … you need to support as much as possible”: a qualitative analysis of teachers’ experiences of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME)

Clinicians’ heuristic assessments of radiographs compared with Kellgren-Lawrence and Ahlbäck ordinal grading: an exploratory study of knee radiographs using paired comparisons

Guidelines for the use of chest radiographs in community-acquired pneumonia in children and adolescents

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