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Copyright of Canadian Journal of Occupational Therapy is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The NHS in the UK faces numerous challenges, including increasing demand for services, financial constraints and the need for effective leadership. Paramedics are exceptional healthcare leaders within the NHS in the UK, possessing unique skill sets and experiences that make them invaluable in leadership roles. Their clinical expertise, decisive decision-making abilities, and adaptability, honed in challenging frontline environments, are crucial assets in healthcare leadership. Transformational and situational leadership theories align seamlessly with paramedic practice, showcasing their ability to inspire teams and effectively navigate diverse healthcare scenarios. Evidence demonstrates paramedics' significant positive impact on patient care, organisational performance, and healthcare innovation when in leadership positions. Despite their capabilities, challenges persist, including historical professional hierarchies and underrepresentation of certain groups in leadership. A new framework for developing paramedic leaders addresses these issues, emphasising targeted training, interprofessional collaboration, and inclusive practices. Recommendations include implementing comprehensive leadership development programmes, enhancing incident scene management training, and addressing psychological factors affecting leadership effectiveness. By fully recognising and nurturing paramedic leadership, the NHS can leverage their unique perspectives to create a more resilient, efficient, and patient-centred healthcare system to meet current and future challenges. [ABSTRACT FROM AUTHOR]

Evidence-based practice (EBP) has been defined as the integration of best available scientific evidence, patient preferences, and individual clinical expertise. A range of barriers for implementing EBP in physiotherapy practice have been identified, but little is known about the underlying causes. The objective was to explore how physiotherapists in private practice perceive EBP, how they use, and what their main challenges are. This study used a convergent parallel mixed-methods design. It consisted of a 28-item questionnaire informed by systematic reviews with a deductive approach and semi-structured interviews with a phenomenological and inductive approach. The results from the questionnaire (n = 216) and the interviews (n = 9) showed that physiotherapists are more likely to implement EBP if they have sufficient flexibility in time allocation to facilitate shared decision-making and increase the integration of patient preferences. Support from colleagues and the workplace culture were identified as both a challenge and a potential facilitator for increased use of EBP. Participants in this study experienced several modifiable challenges, including lack of flexibility in time allocation and insufficient time to build rapport with the patient. Physiotherapists show inconsistency in their understanding of what EBP is – this ultimately becomes an additional and yet undescribed barrier for implementation of EBP. [ABSTRACT FROM AUTHOR]

Simple Summary: A multidisciplinary group researched and defined criteria to describe a sarcoma specialist treatment center or network. The project is led by Sarcoma Patient Advocacy Global Network (SPAGN), involves patient groups from around the world and is supported by clinical specialists and leading researchers. The paper identifies Core Principles and Key Features which define a specialist center/network. They are supported by evidence and experience. A primary aim is that new patients and their families can identify a specialist center which can provide curative treatment. A secondary aim is that countries where specialist treatment is not yet available can identify what they have to achieve to meet that ambition. The Core Principles allow a center or network to attain accreditation as a Sarcoma Intelligent Specialist Network. The Key Features are more aspirational and are expressed in a way that allows local needs, legal considerations and budgetary pressures to be taken into account. This is the first time an expert multidisciplinary group has defined specialism in cancer treatment in a worldwide context. The management of sarcomas in specialist centers delivers significant benefits. In much of the world, specialists are not available, and the development of expertise is identified as a major need. However, the terms 'specialist' or 'expert' center are rarely defined. Our objective is to offer a definition for patient advocates and a tool for healthcare providers to underpin improving the care of people with sarcoma. SPAGN developed a discussion paper for a workshop at the SPAGN 2023 Conference, attended by 75 delegates. A presentation to the Connective Tissue Oncology Society (CTOS) and further discussion led to this paper. Core Principles were identified that underlie specialist sarcoma care. The primary Principle is the multi-disciplinary team discussing every patient, at first diagnosis and during treatment. Principles for optimal sarcoma management include accurate diagnosis followed by safe, high-quality treatment, with curative intent. These Principles are supplemented by Features describing areas of healthcare, professional involvement, and service provision and identifying further research and development needs. These allow for variations because of national or local policies and budgets. We propose the term 'Sarcoma Intelligent Specialist Network' to recognize expertise wherever it is found in the world. This provides a base for further discussion and local refinement. [ABSTRACT FROM AUTHOR]

Background: Migraine is a prevalent, recurrent condition with substantial disease burden. Chinese herbal medicine (CHM) has been used frequently for migraine in controlled clinical settings. This study is to summarise the characteristics of patients who seek clinical care in a tertiary Chinese medicine hospital in China; to gather their preferences and values of using CHM; to explore the effect of CHM for migraine and its comorbidities in a real-world setting, and to collect first-hand expertise of clinicians' practice pattern in prescribing CHM for migraine. Methods: This registry-based cohort study was prospectively conducted at Guangdong Provincial Hospital of Chinese Medicine from December 2020 to May 2022. Adult migraine patients seeking their initial anti-migraine clinical care at the hospital were consecutively recruited and followed up for 12 weeks. Practitioners specialised in headache management prescribed individualised treatments without research interference. Standardised case report forms were employed to gather information on patients' preferences and perspective of seeking clinical care, as well as to assess participants' migraine severity, comorbidities, and quality of life, at 4-weeks intervals. Various analytical methods were utilised based on the computed data. Results: In this study, we observed 248 participants. Of these, 73 received CHM treatment for 28 days or longer. Notably, these participants exhibited a greater disease severity, compared to those treated with CHM for less than 28 days. Of the 248 participants, 83.47% of them expected CHM would effectively reduce the severity of their migraine, around 50% expected effects for migraine-associated comorbidities, while 51.61% expressing concerns about potential side effects. CHM appeared to be effective in reducing monthly migraine days and pain intensity, improving patients' quality of life, and potentially reducing comorbid anxiety, with a minimum of 28 days CHM treatment. Herbs such as gan cao, gui zhi, chuan xiong, fu ling, bai zhu, yan hu suo, etc. were frequently prescribed for migraine, based on patients' specific symptoms. Conclusion: CHM appeared to be beneficial for migraine and comorbid anxiety in real-world clinical practice when used continuously for 28 days or more. [ABSTRACT FROM AUTHOR]

Background: Dental implant placement is a critical procedure in modern dentistry, requiring precise treatment planning to ensure successful outcomes. Traditionally, treatment planning has relied on the expertise of clinicians, but recent advancements in artificial intelligence (AI) have opened up the possibility of AI-assisted treatment planning. Materials and Methods: Twenty patients requiring dental implant placement were included in this comparative study. For each patient, a clinical treatment plan was created by an experienced dentist, while an AI algorithm, trained on a dataset of implant placement cases, generated an alternative plan. Various parameters, including implant position, angulation, and depth, were compared between the two plans. Surgical templates were fabricated based on both plans to guide implant placement accurately. Results: The results of this study indicate that AI-generated treatment plans closely align with clinical plans in terms of implant positioning, angulation, and depth. Mean discrepancies of less than 1 mm and 2 degrees were observed for implant position and angulation, respectively, between the two planning methods. The AI-generated plans also showed a reduction in planning time, averaging 10 min compared to the clinical planning, which averaged 30 min per case. Additionally, the surgical templates based on AI-generated plans exhibited similar accuracy in implant placement as those based on clinical plans. Conclusion: AI-assisted treatment planning for dental implant placement demonstrates promising results in terms of accuracy and efficiency.

Background: Dental implant placement is a critical procedure in modern dentistry, requiring precise treatment planning to ensure successful outcomes. Traditionally, treatment planning has relied on the expertise of clinicians, but recent advancements in artificial intelligence (AI) have opened up the possibility of AI-assisted treatment planning. Materials and Methods: Twenty patients requiring dental implant placement were included in this comparative study. For each patient, a clinical treatment plan was created by an experienced dentist, while an AI algorithm, trained on a dataset of implant placement cases, generated an alternative plan. Various parameters, including implant position, angulation, and depth, were compared between the two plans. Surgical templates were fabricated based on both plans to guide implant placement accurately. Results: The results of this study indicate that AI-generated treatment plans closely align with clinical plans in terms of implant positioning, angulation, and depth. Mean discrepancies of less than 1 mm and 2 degrees were observed for implant position and angulation, respectively, between the two planning methods. The AI-generated plans also showed a reduction in planning time, averaging 10 min compared to the clinical planning, which averaged 30 min per case. Additionally, the surgical templates based on AI-generated plans exhibited similar accuracy in implant placement as those based on clinical plans. Conclusion: AI-assisted treatment planning for dental implant placement demonstrates promising results in terms of accuracy and efficiency. [ABSTRACT FROM AUTHOR]

The ways of substantiating the clinical decision of doctors in the absence of clinical treatment protocols are considered. A comparative evaluation of various statistical methods for ranking clinical symptoms in terms of significance for predicting the outcome of the disease in a small sample of patients with COVID-19 and a history of cardiovascular diseases was performed. The data set (141 patients, 81 factors) was formed based on the materials of electronic medical records of patients of the Federal State Budgetary Institution “National Medical Research Center named after V.A. Almazov”. A subset of controllable risk factors (51 factors) was identified. Descriptive statistics methods (one-way ANOVA, Mann-Whitney and χ² tests) and dimensionality reduction methods (univariate linear regression combined with multiple logistic regression, generalized discriminant analysis, and various decision tree algorithms) were used to rank the factors. To compare the ranking results and evaluate the statistical stability, Kendall’s correlation was used, visualized as a heat map and a positional graph. It has been established that the use of descriptive statistics methods is justified when ranking on a small sample size of patients. It is shown that the ensemble of ranking results may be statistically inconsistent. It is concluded that the positions of the same features obtained by ranking them as part of a complete set and a subset of features do not match; therefore, when choosing a statistical processing method for expert evaluation, one should take into account the meaningful formulation of the problem. It is shown that the statistical stability of ranking under conditions of small samples depends on the number of features taken into account, and this dependence is significantly different for different ranking methods. The proposed method of intellectual support and verification of clinical decisions in terms of choosing the most significant clinical signs can be used to select and justify the tactics of managing patients in the absence of clinical protocols.

Can contemporary cognitive science explain clinical expertise? We argue that the answer could be “no.” In support of this, we provide an analysis of two of the most essential expressions of clinical expertise in nursing and medicine, the ability to run a code blue and the ability to diagnose congestive heart failure. We show how it makes sense to treat both as examples of what we call inference to the best action, and we then argue that two of the standard explanatory paradigms of cognitive science — the Humean and Bayesian paradigms — are unable to provide a plausible analysis of inference to the best action.

Some characteristics of the individual who attends psychotherapy influence its outcomes, these variables being the main factor associated with change. A treatment that is tailored to each case will be much more effective than one that does not adapt to the uniqueness of each client. This paper focuses on one of the factors to take into account, the patient's preferences, a fundamental pillar of evidence-based practice in psychology. Available empirical evidence is reviewed, along with associated clinical implications and recommendations. This is followed by other ethical considerations, which lead to a discussion about the dilemmas that can arise when working with each person's preferences. [ABSTRACT FROM AUTHOR]

The purposes of this study were (1) to introduce a virtual dental lab designed to support students' virtual clinical examinations in a dentistry program in South Korea and (2) to determine how dental students' levels of expertise (low, medium, or high) influence their clinical performance in terms of dwell time on each tooth location, total examination time, and perceived task load in the virtual dental lab. A total of 93 students participated in the study. Participants were assigned to one of three groups based on their expertise levels and performed virtual reality simulation tasks of detecting and diagnosing dental caries in two clinical cases. The outcome variables were participants' clinical examination performance (total dwell time on the virtual dental mirror and total examination time) and perceived task load (separated into six subcomponents: mental demands, physical demands, temporal demands, effort, performance, and frustration). The results suggest that the level of expertise significantly affected the performance of dental examinations in all areas except the anterior maxillary teeth. Both total dwell time on the dental mirror and total examination time were significantly shorter for the high expertise group than for the medium and low expertise groups. In addition, the high expertise group rated task load significantly lower for mental demands (p <.05, Cohen's d = 0.70) and effort (p <.05, Cohen's d = 0.75) than did the low expertise group. [ABSTRACT FROM AUTHOR]

Reliable prediction models of treatment outcome in Major Depressive Disorder (MDD) are currently lacking in clinical practice. Data-driven outcome definitions, combining data from multiple modalities and incorporating clinician expertise might improve predictions. We used unsupervised machine learning to identify treatment outcome classes in 1060 MDD inpatients. Subsequently, classification models were created on clinical and biological baseline information to predict treatment outcome classes and compared to the performance of two widely used classical outcome definitions. We also related the findings to results from an online survey that assessed which information clinicians use for outcome prognosis. Three and four outcome classes were identified by unsupervised learning. However, data-driven outcome classes did not result in more accurate prediction models. The best prediction model was targeting treatment response in its standard definition and reached accuracies of 63.9 % in the test sample, and 59.5 % and 56.9 % in the validation samples. Top predictors included sociodemographic and clinical characteristics, while biological parameters did not improve prediction accuracies. Treatment history, personality factors, prior course of the disorder, and patient attitude towards treatment were ranked as most important indicators by clinicians. Missing data limited the power to identify biological predictors of treatment outcome from certain modalities. So far, the inclusion of available biological measures in addition to psychometric and clinical information did not improve predictive value of the models, which was overall low. Optimized biomarkers, stratified predictions and the inclusion of clinical expertise may improve future prediction models. • Data-driven treatment outcome classes in depressed patients were created. • Outcome classes were not easier to predict than response/remission using baseline data. • Clinical and sociodemographic data were more predictive than biological measures. • Top predictors were compared to clinical expertise from an online survey. [ABSTRACT FROM AUTHOR]

Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients' lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities. [ABSTRACT FROM AUTHOR]

Abstract Background Humility has recently been conceptualized as a positive, multifaceted attribute in fields outside of medicine, such as psychology and philosophy. In medicine, there has been limited study into the nature of humility and its role in clinical practice. We sought to develop a deeper understanding of humility in medical practice through the lived-experiences of peer-nominated excellent clinicians. Methods We conducted a qualitative study with secondary analysis of transcripts from individual open ended, semi-structured interviews of 13 peer nominated physicians [7 (54%) female] at an academic centre. Using constant comparative analysis, the transcripts were analyzed for instances where humility was discussed as it related to clinical practice. Results Participants perceived humility to be an important driver for excellence in clinical practice. This was further explained using two overarching themes: an inward, intellectual perspective and an outward, social perspective. The physician’s inward perspective was their view of their abilities and limits, their self-confidence, and their intellectual openness and adaptability to the limitations and evolving nature of knowledge in medicine. Their outward perspective was an understanding and appreciation for the larger system in which they worked, an openness to others, and valuing patients’ experience. Through these perspectives, humility positively influenced clinical care, learning and curiosity, motivation in the care of others, and relationships with team members and patients. Conclusions Humility in medicine is a rich, multifaceted construct that was perceived to be a driver for excellence in medical practice by peer-nominated excellent clinicians. Humility was seen as an active force in formulating and calibrating a clinician’s perspective of self and of others, and as such, positively influencing clinical practice. These findings will help inform a discourse in medical education and faculty development about the important role of humility in medical practice.

Background: High-quality healthcare decisions need to balance input from science and clinical practice. When two sources of evidence — such as scientific and practice-derived evidence — are compared, integrated, or need to stand-in for one another, they need to be comparable on similar dimensions. Since 1891, Swedish physicians have been operating under a legal requirement to base their healthcare decisions on science and “proven experience” (approximately clinical expertise), and today all healthcare personnel in Sweden fall under this legal requirement. Objectives: We investigated the dynamics between these two kinds of evidence with respect to importance, systematicity, and certainty by studying Swedish healthcare professionals. Design: Survey to professionals; document studies of political discourse. Method: In this study, a survey was sent to simple random samples of Swedish professionals in medicine, nursing, occupational therapy, dentistry, and dental hygiene, asking about the roles of science and proven experience in medical decision making. Outcome measures were how important, certain, and systematic science and proven experience are for successful medical decision making. Participants: The sampling frame was each profession's most recent occupational registry accessed by the Swedish federal statistical agency. 3500 surveys were distributed. 1626 surveys were returned. 26 participants were removed prior to analysis (exclusion criteria: more than one profession indicated, missing certificate, and mistake in stratum). The final sample consisted of 295 physicians, 300 nurses, 365 occupational therapists, 339 dentists, and 301 hygienists. 162 responses in questions used as variables in the analyses were either uninterpretable or empty; those were replaced with the modal response for a given participant's profession on a given question. Results: In the study, proven experience's perceived importance for clinical decision making is positively correlated with its certainty and systematicity, and an increased certainty and systematicity is positively correlated with a diminished difference in importance between science and proven experience for almost all professions surveyed in this study. Conclusions: Proven experience has an evidentiary role in clinical decision making, and this role depends in part on its certainty and systematicity. Notably, this makes the EBM-based perspective that practice-derived knowledge is primarily of implementation value less plausible.

Background: Humility has recently been conceptualized as a positive, multifaceted attribute in fields outside of medicine, such as psychology and philosophy. In medicine, there has been limited study into the nature of humility and its role in clinical practice. We sought to develop a deeper understanding of humility in medical practice through the lived-experiences of peer-nominated excellent clinicians. Methods: We conducted a qualitative study with secondary analysis of transcripts from individual open ended, semi-structured interviews of 13 peer nominated physicians [7 (54%) female] at an academic centre. Using constant comparative analysis, the transcripts were analyzed for instances where humility was discussed as it related to clinical practice. Results: Participants perceived humility to be an important driver for excellence in clinical practice. This was further explained using two overarching themes: an inward, intellectual perspective and an outward, social perspective. The physician's inward perspective was their view of their abilities and limits, their self-confidence, and their intellectual openness and adaptability to the limitations and evolving nature of knowledge in medicine. Their outward perspective was an understanding and appreciation for the larger system in which they worked, an openness to others, and valuing patients' experience. Through these perspectives, humility positively influenced clinical care, learning and curiosity, motivation in the care of others, and relationships with team members and patients. Conclusions: Humility in medicine is a rich, multifaceted construct that was perceived to be a driver for excellence in medical practice by peer-nominated excellent clinicians. Humility was seen as an active force in formulating and calibrating a clinician's perspective of self and of others, and as such, positively influencing clinical practice. These findings will help inform a discourse in medical education and faculty development about the important role of humility in medical practice. [ABSTRACT FROM AUTHOR]

For some years, we have been witnessing a steady stream of high‐profile studies about machine learning (ML) algorithms achieving high diagnostic accuracy in the analysis of medical images. That said, facilitating successful collaboration between ML algorithms and clinicians proves to be a recalcitrant problem that may exacerbate ethical problems in clinical medicine. In this paper, we consider different epistemic and normative factors that may lead to algorithmic overreliance within clinical decision‐making. These factors are false expectations, the miscalibration of uncertainties, non‐explainability, and the socio‐technical context within which the algorithms are utilized. Moreover, we identify different desiderata for bridging the gap between ML algorithms and clinicians. Further, we argue that there is an intriguing dialectic in the collaboration between clinicians and ML algorithms. While it is the algorithm that is supposed to assist the clinician in diagnostic tasks, successful collaboration will also depend on adjustments on the side of the clinician. [ABSTRACT FROM AUTHOR]

After more than two decades of enthusiasm surrounding the concept of evidence based medicine, wide variation in its implementation is still present. Some have suggested that evidence based medicine may be a failed model. We propose that the highly formulaic approach of evidence based medicine has evolved toward a more personalized, integrated and contextualized method, consistent with the principle of shared decision making advanced by the Institute of Medicine. Evidence based medicine remains an essential prerequisite but ultimately, only the practitioner's clinical expertise, knowledge and practical wisdom will provide the ability to apply general rules of evidence to particular clinical situations. [ABSTRACT FROM AUTHOR]

• Training and supervision should use active, performance-oriented strategies to improve practitioner skills. • Train standardized work routines to detect relationships between clinical decisions, interventions, and patient outcomes. • Technology can assist measurement-based care, training, and sustain delivery of evidence-based practices. Practitioners face three challenges in delivering evidence-based practice: limitations in the evidence available to guide routine clinical decisions; limitations in clinical judgment that are hard to remedy with typical work routines; and the practical difficulties of training and sustaining the breadth of skills relevant to meet diverse patient needs in a generalist practice. We recommend designing practice environments that support development of excellent clinical judgment with use of standardized work routines that help detect relationships between clinical decisions, interventions, and patient outcomes. We describe examples illustrating how technology can support training and supervision within this framework. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic led to a violent debate about the efficacy of a repurposed drug hydroxychloroquine (HCQ) and a new broad-spectrum antiviral (remdesivir) and about randomized controlled trials (RCTs) and observational studies. To understand conflicting results in the literature, we performed a metasynthesis to determine whether intrinsic qualitative criteria within studies may predict apparent efficacy or ineffectiveness of HCQ and remdesivir. Methodology: Predictive criteria were identified through critical review of studies assessing HCQ and remdesivir for COVID-19 mortality from March to November 2020. Multiple correspondence analysis, comparative metaanalysis, and predictive value were used to explore and identify criteria associated with study outcomes. Results: Among the 61 included studies, potential conflict of interest, detailed therapeutic protocol, toxic treatment (overdose or use in contraindicated patients), known centers and doctors, and private data computing company were the most predictive criteria of the direction of effect of the studies. All 18 observational studies evaluating HCQ and reporting detailed therapeutic protocol without conflict of interest were Pro. Potential conflict of interest was a perfect predictor for remdesivir efficacy. RCTs were associated with HCQ inefficacy and potential conflict of interest. The most predictive criteria were validated and allowed perfect classification of 10 additional studies. Conclusion: In therapeutic trials on COVID-19, the major biases predicting the conclusions are not methodology nor data analysis, but conflict of interest and absence of medical expertise. The thorough search for declared or undeclared and direct or indirect conflict of interest, and medical expertise should be included in the quality criteria for the evaluation of future therapeutic studies in COVID-19 and beyond. A new checklist evaluating not only methodology but also conflict of interest and medical expertise is proposed. [ABSTRACT FROM AUTHOR]

The Francophone Pain Nursing Group (GIFD) analyzed nursing interventions of the international classification (Nursing Intervention Classification), taking into account the legislation, the nursing discipline, the missions required by the FPS Public Health, and the professional experience members of the group. At the end of this analysis, a consensus was obtained to retain 101 interventions. Among these interventions, 1/3 stipulate activities carried out by algologist nurses, 1/3 activities carried out partially, and 1/3 activities carried out in collaboration. Nine interventions concern non-drug therapies, requiring additional training to current training in algology. This work completes the job profile of the nurse algologist, published in 2009. [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence of intuitive decision-making (IDM) among health care practitioners (HCPs) and explore its person- and job-specific factors. Design and Outcome Measures: We used on-line survey data from a cross-sectional sample of Hungarian physicians and nurses (N = 460) to assess their reliance on IDM. In a second survey we asked physicians (N = 104) to rate medical specialties on dimensions of ‘emergency’ (necessity of making instantaneous decisions in unforeseeable situations) and ‘complexity’ (necessity of considering multiple perceptual and diagnostic aspects of patients’ health condition along with diverse treatment options). Results: Altogether 40% of participants reported ever relying on IDM. Using logistic regression analysis, we found the estimated probability of IDM was 0.24 greater for physicians than for nurses, 0.10 greater for females than for males, and 0.11 greater for advanced level HCPs than for novices. Reaching expert level further increased (by 0.31) the probability of IDM for physicians, but not for nurses. Concerning physicians, practicing in a medical specialty of ‘high likelihood of emergency’ or ‘high complexity’ increased the probability of IDM by 0.25 and 0.23; the same effects for nurses were 0.20 and 0.07. We found some (inconclusive) evidence for education positively influencing HCPs’ propensity for IDM. Additionally, we performed content analysis of participants’ free-text answers to explore the psychological background of IDM instances. HCPs educated in the subject of IDM were found more disposed to perform or request further medical investigation, less prone to deviate from medical protocols, apter to reflect on their mental processes, and more inclined to rely on a large scope of information for their decisions. Conclusions: The associations between job- and person-specific factors and HCPs’ propensity for IDM may have implications for their training and allocation in the health care system. Education has great potential for enhancing the quality of IDM in clinical practice.

Copyright of Revista Psicologia Clínica is the property of Faculdades Catolicas - Pontificia Universidade Catolica do Rio de Janeiro and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Evidence based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values. In the practice of EBM it is the physician’s duty to find the best and most current information and apply it judiciously for the benefit of the patient. The practice of EBM involves formulating a clear clinical question from a patient’s problem, searching the literature to acquire the evidence, then critically appraising the evidence for its validity and usefulness, and applying the results by implementing useful findings into clinical practice, and finally evaluating this application of evidence on patient. An important rule in EBM is that it starts with the patient and ends with the patient. Evidence based medicine requires new skills of the physician, including efficient literature searching and the application of formal rules of evidence evaluation from the clinical literature. Incorporation of EBM into one’s practice will not only make one a better clinician, it also allows one to provide the best possible quality of medical care to his or her patients. Thus EBM can be incorporated as an integral part of the medical curriculum.

This paper historicises the criticisms and backlash from within medicine against new computer technologies in the clinic. Physicians' reactions to proposals for the implementation of algorithmic technologies in the clinic ranged from enthusiastic to cautionary to critical from as early as the 1960s. Clinicians were suspicious of these technologies as they threatened their professional expertise. I argue that these discontent reactions from doctors demonstrate an implicit struggle for authority over clinical spaces and with regards to medicine's place within society more generally. Drawing on Foucault's concept of discursive rules and their function within a closed community, I recover the forgotten debate to include or reject AI and its predecessor technologies of expert systems and neural networks. This paper explains how and why justifications for and against the applicability of AI to the clinic are underpinned by questions of medical authority. I conclude with an inquiry into the transformative possibilities of partisanship. [ABSTRACT FROM AUTHOR]

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Objective: To assess the prevalence of intuitive decision-making (IDM) among health care practitioners (HCPs) and explore its person- and job-specific factors. Design and Outcome Measures: We used on-line survey data from a cross-sectional sample of Hungarian physicians and nurses (N = 460) to assess their reliance on IDM. In a second survey we asked physicians (N = 104) to rate medical specialties on dimensions of 'emergency' (necessity of making instantaneous decisions in unforeseeable situations) and 'complexity' (necessity of considering multiple perceptual and diagnostic aspects of patients' health condition along with diverse treatment options). Results: Altogether 40% of participants reported ever relying on IDM. Using logistic regression analysis, we found the estimated probability of IDM was 0.24 greater for physicians than for nurses, 0.10 greater for females than for males, and 0.11 greater for advanced level HCPs than for novices. Reaching expert level further increased (by 0.31) the probability of IDM for physicians, but not for nurses. Concerning physicians, practicing in a medical specialty of 'high likelihood of emergency' or 'high complexity' increased the probability of IDM by 0.25 and 0.23; the same effects for nurses were 0.20 and 0.07. We found some (inconclusive) evidence for education positively influencing HCPs' propensity for IDM. Additionally, we performed content analysis of participants' free-text answers to explore the psychological background of IDM instances. HCPs educated in the subject of IDM were found more disposed to perform or request further medical investigation, less prone to deviate from medical protocols, apter to reflect on their mental processes, and more inclined to rely on a large scope of information for their decisions. Conclusions: The associations between job- and person-specific factors and HCPs' propensity for IDM may have implications for their training and allocation in the health care system. Education has great potential for enhancing the quality of IDM in clinical practice. [ABSTRACT FROM AUTHOR]

The policy statement for evidence-based practice in psychology is the most important document in contemporary psychotherapy. In its current form, evidence-based practice in psychology gives scientific research precedence in psychotherapy practice. However, psychotherapy practice’s complexity warrants reflection beyond the limits of science. The importance of clinical expert is not recognised in the current policy statement. The clinical expert is necessary to translate psychological research into clinical practice. It is also crucial to identify, clarify and include patient preferences in psychotherapy practice. This paper argues that virtue ethics is a useful theoretical framework for conceptualising clinical expertise. Clinical expertise is conceptualised as the meta-capacity of practical wisdom (phronesis) and the virtues necessary for integrating best available research, clinical expertise and patient preferences.

This document is the second instalment in a two-part series outlining evidence-based recommendations for the treatment of adult patients with depressive disorders. Part II focuses on psychotherapy as an important treatment option – as a standalone treatment or in combination with pharmacotherapy. This guideline adapts the definition of evidence-based practice in psychology, as proposed by the American Psychological Association, to the practice of psychotherapy. As such, evidence-based practice in psychotherapy is anchored in best available research evidence, the psychotherapist’s clinical expertise, and the patient’s characteristics, culture and preferences. The article reviews the best available research evidence for psychological treatments for depression and describes in some detail each of the current empirically-supported treatments with strong and modest research support. Further, it discusses the key components of clinical expertise, as it relates to both the person of the therapist and the process of psychotherapy. In particular, the discussion covers the following key areas of clinical expertise: 1) assessment, diagnosis, and case formulation; 2) treatment planning and implementation and ongoing monitoring of patients’ progress; 3) interpersonal expertise; 4) self-reflection, utilising available resources and ongoing professional growth; 5) scientific expertise; and 6) diversity expertise. Finally, the guideline addresses important patient-related variables and how they should inform treatment in order to maximise its effectiveness.

Objectives: Diagnostic 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. Methods: To 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. Results: Diagnosis 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. Conclusions: The 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. [ABSTRACT FROM AUTHOR]

The policy statement for evidence-based practice in psychology is the most important document in contemporary psychotherapy. In its current form, evidence-based practice in psychology gives scientific research precedence in psychotherapy practice. However, psychotherapy practice's complexity warrants reflection beyond the limits of science. The importance of clinical expert is not recognised in the current policy statement. The clinical expert is necessary to translate psychological research into clinical practice. It is also crucial to identify, clarify and include patient preferences in psychotherapy practice. This paper argues that virtue ethics is a useful theoretical framework for conceptualising clinical expertise. Clinical expertise is conceptualised as the meta-capacity of practical wisdom (phronesis) and the virtues necessary for integrating best available research, clinical expertise and patient preferences. [ABSTRACT FROM AUTHOR]

Context: Advanced clinical practice is inherent in contemporary athletic training education, such as residency programs and Doctor of Athletic Training programs; however, as a concept, advanced clinical practice in athletic training has been poorly studied to date. Objective: To explore athletic trainers' perceptions of advanced clinical practice. Design: Cross-sectional. Setting: Online survey with open-ended questions. Patients or Other Participants: Three hundred fifty of 1992 athletic trainers accessed the survey (17.6% access rate); 321 respondents completed at least 1 open-ended question; and 196 completed the survey in its entirety (61.1% completion rate). Intervention(s): We used a 13-item survey including demographic items (9 items) and open-ended response questions (4 items). Main Outcome Measure(s): Guided by the consensual qualitative research approach, a 3-person data analysis team coded the open-ended responses. Each member coded 50 responses and a consensus codebook was developed. Two members of the team coded the remaining responses, which were confirmed by the third member. Emergent data were organized into themes and categories, and frequency counts were determined for each category. Results: Athletic trainers' definitions of advanced clinical practice were categorized into 4 emergent categories: (1) formal training and education; (2) informal training and education; (3) knowledge, skills, and behaviors; and (4) experience and uncertainty. Conclusions: The categories of formal and informal training and education focused on athletic trainers acquiring additional knowledge and skills through mechanisms such as postprofessional degree programs, residency programs, or other areas of study. The knowledge, skills, and behaviors category included areas related to specialized skills and the core competencies. These 3 categories aligned with one another to provide both the types of knowledge, skills, and behaviors that define advanced clinical practice, and the specific mechanisms through which an athletic trainer can achieve advanced clinical practice. [ABSTRACT FROM AUTHOR]

Background: Quality of life (QOL) is important to people with aphasia and their family members and is influenced by a range of factors within the scope of practice for speech and language therapy. Interestingly though, clinicians largely assess patients'/clients' QOL informally through discussion, and rarely measure QOL as an outcome from aphasia rehabilitation. Research is needed to understand why there is relatively little consideration of QOL in clinical practice and little use of formal assessments. Aims: This study explores aphasia clinicians' views and reported practices regarding QOL as a concept and its assessment. Methods & Procedures: Nineteen practising speech and language therapists working in rehabilitation with adult clients with neurogenic communication disorders volunteered and completed the study. They completed an online survey of 48 questions with a range of response options, including free text. Descriptive and inferential statistics were used for count and categorical data, and content analysis for text responses. Outcomes & Results: These clinicians felt initially unprepared for practice, and had limited awareness, knowledge and confidence in using QOL assessments, but nonetheless thought QOL was important in clinical management. They considered QOL as being individualized, pertaining to life satisfaction and enjoyment, and additionally considered it as communication, participation in activities, education, and emotional support. The majority used informal methods, although some formal assessment use was reported. Many perceived barriers related to lack of resources (physical, staff, and time). Clinicians also reported scope of practice issues with the broader multidisciplinary rehabilitation team and specifically clinical psychology. Conclusions: Training and access to existing available QOL assessments are clear implications from this study. Further research is needed to assess the extent to which these findings are representative of the broader aphasia clinician community in England. [ABSTRACT FROM AUTHOR]

This paper criticises evidence-based practice in psychology (EBPP) for not actually being a tripartite model. According to the American Psychological Association, EBPP is defined as the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. Nonetheless, EBPP fails to be a tripartite model because it is defined by science alone. This paper aims at explaining why this conflation may have come about. It also shows why clinical expertise and patient preferences should be defined extra-scientifically.

BackgroundDeep brain stimulation (DBS) is an innovative treatment for severe obsessive-compulsive disorder (OCD). Electrodes implanted in specific brain areas allow clinicians to directly modulate neural activity. DBS affects symptomatology in a completely different way than established forms of treatment for OCD, such as psychotherapy or medication.ObjectiveTo understand the process of improvement with DBS in patients with severe OCD.MethodsBy means of open-ended interviews and participant observation we explore how expert clinicians involved in the post-operative process of DBS optimization evaluate DBS effects.ResultsEvaluating DBS effect is an interactive and context-sensitive process that gradually unfolds over time and requires integration of different sources of knowledge. Clinicians direct DBS optimization toward a critical point where they sense that patients are being moved with regard to behavior, emotion, and active engagement, opening up possibilities for additional cognitive behavioral therapy (CBT).DiscussionBased on the theoretical framework of radical embodied cognitive science (RECS), we assume that clinical expertise manifests itself in the pattern of interaction between patient and clinician. To the expert clinician, this pattern reflects the patient’s openness to possibilities for action (“affordances”) offered by their environment. OCD patients’ improvement with DBS can be understood as a change in openness to their environment. The threshold for patients to engage in activities is decreased and a broader range of daily life and therapeutic activities becomes attractive. Movement is improvement.

Background: Deep brain stimulation (DBS) is an innovative treatment for severe obsessive-compulsive disorder (OCD). Electrodes implanted in specific brain areas allow clinicians to directly modulate neural activity. DBS affects symptomatology in a completely different way than established forms of treatment for OCD, such as psychotherapy or medication. Objective: To understand the process of improvement with DBS in patients with severe OCD. Methods: By means of open-ended interviews and participant observation we explore how expert clinicians involved in the post-operative process of DBS optimization evaluate DBS effects. Results: Evaluating DBS effect is an interactive and context-sensitive process that gradually unfolds over time and requires integration of different sources of knowledge. Clinicians direct DBS optimization toward a critical point where they sense that patients are being moved with regard to behavior, emotion, and active engagement, opening up possibilities for additional cognitive behavioral therapy (CBT). Discussion: Based on the theoretical framework of radical embodied cognitive science (RECS), we assume that clinical expertise manifests itself in the pattern of interaction between patient and clinician. To the expert clinician, this pattern reflects the patient's openness to possibilities for action ("affordances") offered by their environment. OCD patients' improvement with DBS can be understood as a change in openness to their environment. The threshold for patients to engage in activities is decreased and a broader range of daily life and therapeutic activities becomes attractive. Movement is improvement. [ABSTRACT FROM AUTHOR]

This paper criticises evidence-based practice in psychology (EBPP) for not actually being a tripartite model. According to the American Psychological Association, EBPP is defined as the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. Nonetheless, EBPP fails to be a tripartite model because it is defined by science alone. This paper aims at explaining why this conflation may have come about. It also shows why clinical expertise and patient preferences should be defined extra-scientifically. [ABSTRACT FROM AUTHOR]

There is a need for studies that advance our knowledge of therapist effectiveness, expanding the definition of what constitutes therapeutic success. In the present study, four aspects of clinical outcome were analyzed using a sample of highly experienced psychotherapists (mean years of experience as therapy practitioners = 30) who also serve as clinical teachers. The four aspects were: (1) overall change in different outcome domains, including long-term outcome; (2) outcome with clinically distressed clients (i.e. clients above the level of clinical disturbance at pretreatment); (3) level of drop-out; and (4) the degree to which clients re-entered treatment during the follow-up period. Participants were 48 clients treated by 18 therapists. Treatments were open-ended, 'therapy as usual', mostly within the setting of independent private practice. Outcome measurements included the OQ-45.2 and IIP-64, with repeated measurements during therapy and extended long-term follow up (up to 3.5 years). Cohen's d effect sizes and multilevel growth trajectories were estimated for patient change in symptomatic and interpersonal distress. The findings indicate that these therapists obtain very good outcomes overall, particularly with clients above cut-off for clinical disturbance. Moreover, there was a high level of maintenance and increase of treatment gains over time. No clients dropped out. Overall, the findings suggest that a sample of highly experienced therapists obtains particularly good outcomes as defined in more comprehensive terms than what is typical in psychotherapy research. Implications for the understanding of therapeutic success and clinical expertise are discussed. [ABSTRACT FROM AUTHOR]

The role of the nurse consultant is often one that is misunderstood. In theory, we are clear about our roles, but our colleagues and organisations sometimes are not, and this can, on occasion, lead to a great deal of time and effort being wasted on explaining the role of the nurse consultant and even justifying the existence of the post. Questions such as 'How do they differ from specialist nurses and advanced nurse practitioners?' and 'What is their role?' are common [ABSTRACT FROM AUTHOR]

This document is the second instalment in a two-part series outlining evidence-based recommendations for the treatment of adult patients with depressive disorders. Part II focuses on psychotherapy as an important treatment option - as a standalone treatment or in combination with pharmacotherapy. This guideline adapts the definition of evidence-based practice in psychology, as proposed by the American Psychological Association, to the practice of psychotherapy. As such, evidence-based practice in psychotherapy is anchored in best available research evidence, the psychotherapist's clinical expertise, and the patient's characteristics, culture and preferences. The article reviews the best available research evidence for psychological treatments for depression and describes in some detail each of the current empirically-supported treatments with strong and modest research support. Further, it discusses the key components of clinical expertise, as it relates to both the person of the therapist and the process of psychotherapy. In particular, the discussion covers the following key areas of clinical expertise: 1) assessment, diagnosis, and case formulation; 2) treatment planning and implementation and ongoing monitoring of patients' progress; 3) interpersonal expertise; 4) self-reflection, utilising available resources and ongoing professional growth; 5) scientific expertise; and 6) diversity expertise. Finally, the guideline addresses important patient-related variables and how they should inform treatment in order to maximise its effectiveness. [ABSTRACT FROM AUTHOR]

Background: Central venous catheter-related infections (CVCIs) in patients on maintenance hemodialysis (HD) have been documented due to unsafe/unsterile manipulations by nurses during HD machine deconnection and reconnection. Given the gravity of CVCIs in HD patients using catheter access, precise, safe installation of the device, and good nursing technique are crucial. Aim: To assess and compare safety performance and complications of a Y-connection (n=133) versus the usual tunneled central venous catheter (CVC) technique (n=73) among HD patients and then explore preferences between techniques among patients and frontline HD nurses. Materials and methods: A prospective, comparative, 3-month point prevalence survey was conducted among HD outpatients and frontline HD nurses in a 600-bed teaching hospital in the canton of Valais. Results: Nine HD outpatients (average age, 68.3 years; SD=12.3) were recruited. The two techniques showed no differences in C-reactive protein levels (p=0.465), pain (p=1.00), or local complications due to dressings soiled by exudate at the catheter insert point (p=0.066). The relative risk ratio (RR) indicated that CVCI was 1.667 times (95% CI; 0.437, 6.358, p=0.50) more likely with a Y-connection. Neither the Y-connection technique (RR 1.63; [95% CI; 0.554, 4.790]; p=0.32) nor usual CVC technique (RR 0.58; [95% CI; 0.277, 1.217]; p=0.13) were significant relative risk factors for complications. Fifty-seven percent of HD patients stated that they felt more secure and comfortable using the Y-connection technique than the usual care technique. Eleven of the 12 nurses involved preferred the Y-connection technique, feeling that is was safer and easier in use. Conclusion: No difference was found in the complication rates of two blood restitution techniques - the Y-connection versus the usual CVC technique. HD outpatients and nurses preferred the Y-connection for blood restitution. [ABSTRACT FROM AUTHOR]

Purpose: The Swedish government initiated an investigation of how to secure and develop the competence of the occupational health services. The primary aim of the present study was to investigate whether the development of evidence-based practice (EBP) in the Swedish occupational health services in relation to attitudes, knowledge and use improved during the first 3 years of the government's initiative. Methods: The study has a mixed methods design combining questionnaires and interviews with data collection at baseline and at 3-year follow-up. Results: The response rate was 66% at baseline and 63% at follow-up. The results show that practitioners' knowledge of EBP was moderate at baseline and improved at follow-up ( p = 0.002; 95% CI 0.01; 0.21). Practitioners experienced lower levels of organizational and managerial support for EBP at follow-up ( p < 0.001; 95% CI 0.18; 0.38). The results revealed that managers viewed responsibility for implementing EBP as a matter for individual practitioners rather than as an organizational issue. Conclusions: Occupational health service managers and practitioners are generally positive to EBP. However, the findings emphasize the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS. [ABSTRACT FROM AUTHOR]

CREDO is a framework for understanding human expertise and for designing and deploying systems that support cognitive tasks like situation and risk assessment, decision-making, therapy planning and workflow management. The framework has evolved through an extensive program of research on human decision-making and clinical practice. It draws on concepts from cognitive science, and has contributed new results to cognitive theory and understanding of human expertise and knowledge-based AI. These results are exploited in a suite of technologies for designing, implementing and deploying clinical services, early versions of which were reported by Das et al. (1997) [9] and Fox and Das (2000) [26]. A practical outcome of the CREDO program is a technology stack, a key element of which is an agent specification language (PROforma: Sutton and Fox (2003) [55]) which has proved to be a versatile tool for designing point of care applications in many clinical specialties and settings. Since software became available for implementing and deploying PROforma applications many kinds of services have been successfully built and trialed, some of which are in large-scale routine use. This retrospective describes the foundations of the CREDO model, summarizes the main theoretical, technical and clinical contributions, and discusses benefits of the cognitive approach. [ABSTRACT FROM AUTHOR]

Background The Veterans Health Administration's Office of Nursing Services launched several initiatives to support evidence-based practice (EBP) initiatives throughout its system. From evaluation of these initiatives and reflection on discussions with nurse leaders and direct care nurses, our thinking about and approach to EBP has evolved from a project-focused to a practice-focused interpretation. Purpose (a) Offer an expanded view that moves beyond interpreting EBP as process-driven projects to a “way of practicing” where nurses assume ownership for a practice that integrates best available evidence, clinical expertise, and patient preferences, and (b) describe and generate discussion on the educational, cultural, and role modeling implications of this expanded view. Methods We illustrate EBP integration using a point-of-care interaction scenario. Conclusion Commitment to EBP is reflected at the point-of-care where each nurse demonstrates the ability to integrate evidence-based interventions, patient preferences, and clinical expertise to arrive at patient-centric health care decisions. [ABSTRACT FROM AUTHOR]

Purpose – The evidence base for what works with forensic patients in high-security inpatient settings has typically focused on outcome research and not included clinical expertise from practice-based experience, which is an important facet of evidence-based practice. The purpose of this paper is to establish whether experts with clinical and/or research experience in this setting could reach consensus on elements of high-security hospital services that would be essential to the rehabilitation of forensic patients. Design/methodology/approach – A three-round Delphi survey was conducted to achieve this aim. Experts were invited to rate agreement with elements of practice and interventions derived from existing research evidence and patient perspectives on what worked. Experts were also invited to propose elements of hospital treatment based on their individual knowledge and experience. Findings – In the first round 54 experts reached consensus on 27 (out of 39) elements that included physical (e.g. use of CCTV), procedural (e.g. managing restricted items) and relational practices (e.g. promoting therapeutic alliances), and to a lesser extent-specific medical, psychological and social interventions. In total, 16 additional elements were also proposed by experts. In round 2 experts (n=45) were unable to reach a consensus on how essential each of the described practices were. In round 3 (n=35), where group consensus feedback from round 2 was provided, consensus was still not reached. Research limitations/implications – Patient case complexity, interventions with overlapping outcomes and a chequered evidence base history for this population are offered as explanations for this finding alongside limitations with the Delphi method. Practical implications – Based on the consensus for essential elements derived from research evidence and patient experience, high-secure hospital services might consider those practices and interventions that experts agreed were therapeutic options for reducing risk of offending, improving interpersonal skills and therapeutic interactions with patients, and mental health restoration. Originality/value – The study triangulates what works research evidence from this type of forensic setting and is the first to use a Delphi survey in an attempt to collate this information. [ABSTRACT FROM AUTHOR]

Summary This Masterclass explores how practitioners may develop clinical expertise. The terms expert and expertise are initially outlined along with the attributes of a practitioner with expertise. This is followed by an exploration of the literature in relation to three key ways to develop expertise: through experience with patients, formal postgraduate education and through direct observation of practice with a mentor. The theoretical basis of these activities is critically reviewed to highlight their underpinning educational value and pedagogy. It is proposed that critical reflection on practice enhanced by direct observation of practice with a mentor and formal postgraduate education each provide a potentially powerful tool for learning and the development of clinical expertise. [ABSTRACT FROM AUTHOR]

The concept of 'clinical expertise' is described as a part of evidence-based practice (EBP) together with 'external scientific evidence' and 'patient values and perspectives'. However, clinical expertise in the management of voice disorders has not been described or discussed in much detail. The expertise seems to consist partly of silent know-how that, from the outside, may seem improperly related to the personality of the speech-language pathologist or exclusively dependent on the number of years in the field. In this paper, it is suggested that clinical expertise in voice therapy consists of specific skills that can be explicitly described and trained. These skills are discussed together with educational aspects that contribute to the development of clinical expertise. The skills are also discussed from the perspectives of the past, present, and future. [ABSTRACT FROM AUTHOR]