Data, Models and Earth History in Deep Convolution: Paleoclimate Simulations and their Epistemological Unrest.

Data, Models and Earth History in Deep Convolution: Paleoclimate Simulations and their Epistemological Unrest. Climate and Earth system models are not only used to project future conditions but also to re-construct past climatic events. This is the second in a series of papers1 that argue that paleoclimatology, the study of climate prior to the period of direct, instrumental measurements, is an epistemically radical field, one which directly abolishes the distinction between data and model, and reconfigures the notion of experiment. In doing so our notion of deep (or geological) and shallow (or historical) time has become convoluted. The present paper shows, first, how the introduction of general circulation models not only shifted the analysis of the complex causes and processes of ancient climatic change toward numerical simulation techniques, but also how this very introduction was accompanied, if not also fundamentally impacted upon, by paleoclimatic questions in the first place. Second, these computer experiments, and the temporal processes and scales they make operative, turn out to be a potent catalyst in bringing about a new sense of the temporality in which our present transition into the Anthropocene unfolds. By discussing the historical development of paleoclimate modeling, and through examining the productive heuristic qualities of its practices, this paper introduces the unconventional and pragmatic episteme by which paleoclimate simulation challenges our fixation with the category of uncertainty.

Risks in the Making: The Mediating Role of Models in Water Management and Civil Engineering in the Netherlands.

Risks in the Making: The Mediating Role of Models in Water Management and Civil Engineering in the Netherlands. Reliance on models can make technological cultures susceptible to risks through the assumptions, uncertainties, and blind spots that may accompany modeling practices. Historian of science Peter Galison has described computer modeling practices as "trading zones", conceptual spaces in which a shared language is hammered out in an attempt to facilitate collaboration between different social groups, such as engineers and policymakers. Although such a shared language may enable collaboration between diverse groups, it may also make the relation between modeling practices and knowledge of risks less visible, since the shared language does not necessarily acknowledge how models produce knowledge about their world. In that respect, models have a 'mediating' role, since they are not straightforward representations of the world, but involve a process of translating phenomena into formalized representations that enable experimentation. Drawing on insights from Science and Technology Studies (STS) and empirical work in the domains of hydrology, hydrodynamics, geotechnical engineering, and ecology, this paper emphasizes the importance of understanding the mediating role of models in shaping the understanding that various actors hold with regard to water-related risks. Failing to appreciate the mediating role of models hampers the ability of actors to understand the assumptions, uncertainties, and blind spots that accompany simulation practices, and may put technological cultures at risk.

[Impact of an elective course in evidence-based clinical decision-making on competencies and attitudes of medical students: A pilot study]. / Auswirkungen eines Wahlfachs zur evidenzbasierten klinischen Entscheidungsfindung auf die Kompetenzen und Einstellungen von Medizinstudierenden: Eine Pilotstudie.

BACKGROUND: Evidence-based medicine (EbM) as a teaching subject is increasingly taken into account in the Master Plan 2020. To date, neither theoretical requirements nor practical applications of EbM have been consistently implemented in the clinical curriculum. To fill this gap, a digital and tutor-based EbM course has been developed. The aim is to identify the student characteristics (statistical competence, Need for Cognition (NFC), work and experience patterns (AVEM), diagnostic uncertainty) of the first cohort in order to ensure successful course implementation and to prepare future doctors for their role as mediators of health literacy using EbM methods. METHODS: The long-term study started in the summer term 2019 with 10 medical students during their clinical training. The measurements were conducted before (t0) and after course attendance (t1). Socio-demographic variables were taken at t0, the Quick Risk Test, PRU questionnaire, the NFC scale and the AVEM were collected at t0 and t1. RESULTS: Half of the students started their doctoral thesis before attending the course. The first test results of the Quick Risk Test (t0) were between 50 % and 90 % and at t1 between 60 % and 100 %. The students showed high scores on the NFC scale (X¯=4.6, SD=0.52, Δ X¯ t0 - t1=0.1) and medium scores on the Perfectionism scale (X¯=3.8, SD=0.51, Δ X¯ t0 - t1=0.1), Resignation Tendency (X¯=3.8, SD=1.17, Δ X¯ t0 - t1=0.1) and on the scale Aggressive Problem Solving (X¯=3.9, SD=1.06, Δ X¯ t0 - t1=0.2). They achieved high levels of Anxiety Due to Diagnostic Uncertainty (X¯=4.8, SD=0.69, Δ X¯ t0 - t1=0.4) and on the scale Concern about Poor Outcomes (X¯=3.9, SD=1.54, Δ X¯ t0 - t1=0.6). The scale Restraint in Disclosing Uncertainty to Patients was more pronounced than the scale Restraint in Disclosing Errors to Physicians (X¯=3.5, SD=0.93, Δ X¯ t0 - t1=-0.3 compared to X¯=2.3, SD=1.20, Δ X¯ t0 - t1=0.1). DISCUSSION: Statistical competence improved with course attendance, with only one student being able to correctly answer all items at t1. NFC and AVEM were strongly expressed and were not very sensitive to change in the sample. The greatest changes were observed on the scales of concern about poor results and fear of diagnostic uncertainty, both of which decreased with course participation. CONCLUSION: In the long term, the development of a new measuring instrument to assess EbM competencies instead of the Quick Risk Test is conceivable. The longitudinal design will also enable us to make causal interpretations and to track changes in students' competence feelings, behaviour and attitudes.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

COVID-19, precarity and loneliness.

In this paper I discuss Jungian psychological work of the trauma and loss experienced in reaction to COVID-19 with a man who represents a clinical composite. The issues of precarity, a concept used by the philosopher Judith Butler, are combined with the notions of lack and absence of French psychoanalyst André Green. The psychological and societal situation of precarity aroused the man's childhood issues that were long repressed. The loneliness, isolation and death from COVID-19 mirrored his personal and the collective responses to the disaster from this global pandemic. He felt on the edge of collapse as what he knew of his world crashed and he found himself unable to cope. The subsequent Jungian work taking place through the virtual computer screen was taxing and restorative simultaneously for both analyst and analysand.

Dans cet article je discute le travail psychologique Jungien sur le traumatisme et la perte dont fait l'expérience un patient en réaction au COVID-19, patient qui représente un composite clinique. Les questions en lien avec la précarité, un concept utilisé par la philosophe Judith Butler, sont combinées avec les notions de manque et d'absence chez le psychanalyste français André Green. La situation psychologique et sociale de précarité a activé les problèmes de l'enfance de cet homme, réprimés depuis longtemps. La solitude, l'isolement et la mort liés au COVID-19 ont fait miroir avec ses réponses personnelles et les réponses collectives au désastre de cette pandémie globale. Il se sentit à la limite de l'effondrement alors que ce qu'il connaissait de son monde s'écroulait et il se trouva dans l'incapacité de faire face. Le travail Jungien qui s'ensuivit, au moyen de l'écran virtuel de l'ordinateur fut éprouvant et réparateur pour l'analysant et l'analyste simultanément.

En el presente trabajo, describo el trabajo psicológico Junguiano, con un hombre que representa un compuesto clínico, acerca del trauma y la pérdida experimentada en reacción al COVID-19. Cuestiones de precariedad, un concepto utilizado por la filósofa Judith Butler, son combinadas con las nociones de falta y ausencia del psicoanalista francés André Green. La situación psicológica y social de precariedad activa temas infantiles del individuo, hasta entonces reprimidos. La soledad, aislamiento y muerte del COVID-19 espejó la suya personal y las respuestas colectivas al desastre de esta pandemia global. Él se encontró en el borde del colapso debido a que lo que él conocía del mundo se quebró, y se encontró imposibilitado de hacer algo con esto. El trabajo Junguiano subsiguiente que tuvo lugar a través de la pantalla virtual de la computadora fue arduo y restaurador simultáneamente para ambos, analista y analizando.

[How do young general practitioners experience the transition to general practice? A qualitative study]. / Wie erleben junge Allgemeinärzt*innen den Übergang in die hausärztliche Praxis? Eine qualitative Studie.

BACKGROUND: Although the role of general practice has been strengthened in recent years, undergraduate teaching at medical schools and the clinical phase of specialist training remain dominated by specialized care of seriously ill people in hospitals. It is to be assumed that young doctors' views on medical care are strongly shaped by this clinical focus. OBJECTIVE: To investigate how young general practitioners (GPs) perceive transition from medical school and hospital work to general practice. METHODS: In a qualitative study, a total of 13 physicians in specialist training for general practice as well as general practitioners who had completed their specialist examination up to two years ago participated in problem-oriented interviews. The interviews were analyzed using content analysis. RESULTS: The significant differences between hospital-based and primary care practice initially came as quite a shock to the study participants. Key differences and challenges compared to working in a hospital included: 1) the totally different type of patients or complaints they faced; 2) learning that in many situations one can and should bide one's time ("wait-and-see" approach); 3) ruling out avoidable dangerous developments in patients reliably and coping with the corresponding residual risk; 4) the discovery that sometimes it makes sense not to make a diagnosis; 5) that the doctor-patient relationship should be more cooperative in general practice; and 6) that GPs are often under pressure to act although there is no clear need for taking action or no clear treatment option from a medical and scientific point of view. CONCLUSIONS: Our findings confirm that young doctors' initial views on medical care are strongly shaped by the clinical focus of medical schools and hospital work. Working in general practice is perceived as being very different from working in a hospital.

[Between precision medicine and symbolic mastery: What doctors want]. / Zwischen Präzisionsmedizin und symbolischer Bewältigung: Was Ärzte wünschen.

INTRODUCTION: Caring for patients is inevitably fraught with uncertainties. These may result from clinicians not having or not using the available knowledge, from the incompleteness of the medical science base as a whole, or from the inevitable randomness of biological, psychological and social phenomena. Advances in science promise to reduce uncertainty by making ever more precise diagnosis and treatment possible. METHODS: Here, we discuss two typical examples of scientific progress and on how they impact on clinical uncertainty: first, the stratification of chemotherapy for early breast cancer by a 70-gene signature, and second, the interpretation of knee MRI regarding meniscal damage. RESULTS: According to a large randomized trial, the 70-gene -signature successfully differentiates between strata for invasive treatments. The quantitative results and related trade-offs, however, pose considerable difficulties for patient information and shared decision-making, thus increasing uncertainty. Knee complaints are only weakly associated with MRI findings. Pathological findings are highly prevalent in symptom-free individuals. CONCLUSION: Recent advances in diagnostic methods increase the cognitive demands on clinicians and thus their uncertainty. By uncritically using advanced technologies in their practice, physicians exploit their archetypical healing powers. In a paradoxical way, modern technologies reduce uncertainties felt by doctors and their patients in an archaic fashion.

'Thank God I'm not a Jungian'.

This article focuses less on the content of Jung's ideas than on ways in which they act as both invitation and challenge to engage with psyche. It explores the mythic framework of Jung's approach and how this can enable individuals to live in psychological and mundane worlds in which there can be no final certainties. It elaborates three particular aspects of Jung's thinking that I have found personally valuable: his generosity of vision, his insistence that individuals engage for and with themselves rather than relying on someone else's ideas, and his ponderings on the relationship between the individual and the collective. All three aspects seem to be important elements of the work of individuation.

[Dealing with uncertainty--the hypermodernity of general practice]. / Umgang mit Unbestimmtheit--zur Hypermodernität des Hausarztes.

The general practitioner is fundamentally dealing with uncertainty. On the one hand, we want to demonstrate that uncertainty cannot simply be stipulated as a matter of fact. Instead, we will show that this uncertainty is a performative effect of the primary care setting. On the other hand, we want to point out that the general practitioner's ability to bear uncertainty is a genuinely hypermodern way of productively dealing with uncertainty.

[Dealing with diagnostic uncertainty in general practice]. / Umgang mit diagnostischer Unsicherheit in der Hausarztpraxis.

In general, the prevalence of diseases is low in primary care. Therefore, the positive predictive value of diagnostic tests is lower than in hospitals where patients are highly selected. In addition, the patients present with milder forms of disease; and many diseases might hide behind the initial symptom(s). These facts lead to diagnostic uncertainty which is somewhat inherent to general practice. This narrative review discusses different sources of and reasons for uncertainty and strategies to deal with it in the context of the current literature. Fear of uncertainty correlates with higher diagnostic activities. The attitude towards uncertainty correlates with the choice of medical speciality by vocational trainees or medical students. An intolerance of uncertainty, which still increases as medicine is making steady progress, might partly explain the growing shortage of general practitioners. The bio-psycho-social context appears to be important to diagnostic decision-making. The effect of intuition and heuristics are investigated by cognitive psychologists. It is still unclear whether these aspects are prone to bias or useful, which might depend on the context of medical decisions. Good communication is of great importance to share uncertainty with the patients in a transparent way and to alleviate shared decision-making. Dealing with uncertainty should be seen as an important core component of general practice and needs to be investigated in more detail to improve the respective medical decisions.