Dear Toby
I would be very interested in reading more regarding your proposed
methodology.
In the late 1980s, Patricia Benner adapted a phenomenological methodology
from Dreyfus and Dreyfus's work on the development of expertise in pilots
and published a very influential (perhaps overly so) work on expertise in
nursing. One of the skills Benner illuminated was rapid assessment of
impending problems, in spite of the clinical signs. Unfortunately, she did
not go on to explore this skill in greater depth, probably because she was
working with a group of nurses with different backgrounds. But the "real
world" signs you elucidated have a distinct ring of truth about them.
Since I got into teaching EBH to advanced practice nurses, I have been
struck by the same difficulties in teaching the concepts behind 2x2 tables
(and diagnostic tests) to a group who can see the possible application in
medicine, but not necessarily to nursing. Yet in hospital-based nursing,
there must be a point at which an expert nurse - the good nurse in doc's
terms - decides it is time to alert a medical practitioner of the patient's
need for further assessment; I don't believe this is just the boundary that
delineates the nurse's scope of practice having been reached. I have thought
in the past that this could be tested using the methodology of diagnostic
testing, if only nursing could throw some light on what exactly it was that
was alerting the nurse to the presence of a problem. If I may be so bold, it
looks like you are going down a similar track yourself.
kind regards
Andrew Jull
> -----Original Message-----
> From: Toby Lipman [SMTP:[log in to unmask]]
> Sent: Wednesday, 5 April 2000 22:48
> To: Marjan Kljakovic
> Cc: EVIDENCE BASED HEALTH
> Subject: Re: daunting 2x2 tables
>
> In message <l03130304b51020181ac4@[139.80.144.142]>, Marjan Kljakovic
> <[log in to unmask]> writes
> > However many GPs commented that "we dont
> >go by the pulse" or "I judge what to do by how sick the child looks". So
> I
> >guess the influence of observation at a level of multiple covariation is
> >still present.
> >
> >It takes training to focus on a single co-variation. 2x 2 tables are
> >"abnormal" in the sense that we do not naturally see single co-variation.
> >It is for this reason that it is up to those of us who want to improve on
> >the use of 2x 2 tables or likelihood ratios, to make them easy to use and
> >make them part of the "habits needed to be a doctor".
> >
> >Unfortunately statistical manipulation of multiple co-variation is
> >extremely complex. Furthermore, such modelling is likely to remain as
> >academic interest for a while yet - at least as long as it remains slower
> >than a GP noticing (almost instantly) that a child is "sick".
> >
>
> I've been interviewing GPs to find out how they decide if children are
> sick or not. They do exactly as Marjan says and most claim that they can
> recognise "ill" or "not ill" more or less instantly. They describe this
> as a "gut feeling", but when questioned more closely mention alertness
> ("is the child interested in his/her surroundings?"), normal behaviour
> (playing with toys, watching TV) as opposed to being disinterested or
> "distant", co-operation with (or "naughty" resistance to) examination as
> opposed to distress. Most claim that it took them 2-3 years to learn how
> to do this reliably (or at least to trust their judgment) and they
> rarely have to change their first impression (of serious vs not serious)
> after clinical examination.
>
> I'm setting up a cohort study to measure the sensitivity and specificity
> of these signs/observations in acutely ill children. The outcome
> measures are "real life" rather than "gold standard" and include further
> contact with GP, out of hours contact, admission to hospital.
>
> Where doctors use a combination of experience and clinical skills to
> make decisions it seems to me sensible to measure their effectiveness -
> I suspect that it will be high, perhaps higher than many conventional
> diagnostic tests.
>
> Cheers
>
> Toby
>
> --
> Toby Lipman
> General practitioner, Newcastle upon Tyne
> Northern and Yorkshire research training fellow
>
> Tel 0191-2811060 (home), 0191-2437000 (surgery)
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