Clinical reasoning in pharmacy: What do eye movements and verbal protocols tell us about the processing of a case task?

This study investigates pharmacy students' reasoning while solving a case task concerning an acute patient counselling situation in a pharmacy. Participants' (N = 34) reasoning processes were investigated with written tasks utilizing eye-tracking in combination with verbal protocols. The case was presented in three pages, each page being followed by written questions. Eye movements were recorded during case processing. Success in the task required differentiating the relevant information from the task redundant information, and initial activation of several scripts and verification of the most likely one, when additional information became available. 2nd (n = 16) and 3rd (n = 18)-year students' and better and worse succeeding students' processes were compared. The results showed that only a few 2nd-year students solved the case correctly, whereas almost all of the 3rd-year students were successful. Generally, the average total processing times of the case material did not differ between the groups. However, better-succeeding and 3rd-year students processed the very first task-relevant sentences longer, indicating that they were able to focus on relevant information. Differences in the written answers to the 2nd and 3rd question were significant, whereas differences regarding the first question were not. Thus, eye-tracking seems to be able to capture illness script activation during case processing, but other methods are needed to depict the script verification process. Based on the results, pedagogical suggestions for advancing pharmacy education are discussed.

Conceptual changes for and during working life.

Rapid and radical changes in science, technology and society may result in new scientific concepts and new workplace practices, which require fundamental restructuring of prior knowledge. Over the years a noteworthy body of research has documented the processes of conceptual change, the learning mechanisms involved, and the instructional methods and strategies that can promote conceptual changes. This research, however, focused young learners in school settings. Conceptual changes in working life go beyond traditional conceptual change consisting of processes and mechanisms that involve the interaction between expertise development and workplace learning processes.This Special Issue investigates whether and how conceptual change research can be extended from learning in schools to learning in professional life.

To guide or to follow? Teaching visual problem solving at the workplace.

Visual problem solving is essential to highly visual and knowledge-intensive professional domains such as clinical pathology, which trainees learn by participating in relevant tasks at the workplace (apprenticeship). Proper guidance of the visual problem solving of apprentices by the master is necessary. Interaction and adaptation to the expertise level of the learner are identified as key ingredients of this guidance. This study focuses on the effect of increased participation of the learner in the task on the interaction and adaptation of the guidance by masters. Thirteen unique dyads consisting of a clinical pathologist (master) and a resident (apprentice) discussed and diagnosed six microscope images. Their dialogues were analysed on their content. The dyads were divided in two groups according to the experience of the apprentice. For each dyad, master and apprentice both operated the microscope for half of the cases. Interaction was operationalised as the equal contribution of both master and apprentice to the dialogue. Adaptation was operationalised as the extent to which the content of the dialogues was adapted to the apprentice's level. The main hypothesis stated that the interaction and adaptation increase when apprentices operate the microscope. Most results confirmed this hypothesis: apprentices contributed more content when participating more and the content of these dialogues better reflected expertise differences of apprentices. Based on these results, it is argued that, for learning visual problem solving in a visual and knowledge-intensive domain, it is not only important to externalise master performance, but also that of the apprentice.

Expertise in clinical pathology: combining the visual and cognitive perspective.

Expertise studies in the medical domain often focus on either visual or cognitive aspects of expertise. As a result, characteristics of expert behaviour are often described as either cognitive or visual abilities. This study focuses on both aspects of expertise and analyses them along three overarching constructs: (1) encapsulations, (2) efficiency, and (3) hypothesis testing. This study was carried out among clinical pathologists performing an authentic task: diagnosing microscopic slides. Participants were 13 clinical pathologists (experts), 12 residents in pathology (intermediates), and 13 medical students (novices). They all diagnosed seven cases in a virtual microscope and gave post hoc explanations for their diagnoses. The collected data included eye movements, microscope navigation, and verbal protocols. Results showed that experts used lower magnifications and verbalized their findings as diagnoses. Also, their diagnostic paths were more efficient, including fewer microscope movements and shorter reasoning chains. Experts entered relevant areas later in their diagnostic process, and visited fewer of them. Intermediates used relatively high magnifications and based their diagnoses on specific abnormalities. Also, they took longer to reach their diagnosis and checked more relevant areas. Novices searched in detail, described findings by their appearances, and uttered long reasoning chains. These results indicate that overarching constructs can justly be identified: encapsulations and efficiency are apparent in both visual and cognitive aspects of expertise.

Expertise under the microscope: processing histopathological slides.

OBJECTIVES: Although the obvious goal of training in clinical pathology is to bring forth capable diagnosticians, developmental stages and their characteristics are unknown. This study therefore aims to find expertise-related differences in the processing of histopathological slides using a combination of eye tracking data and verbal data. METHODS: Participants in this study were 13 clinical pathologists (experts), 12 pathology residents (intermediates) and 13 medical students (novices). They diagnosed 10 microscopic images of colon tissue for 2 seconds. Eye movements, the given diagnoses, and the vocabulary used in post hoc verbal explanations were registered. Eye movements were analysed according to changes over trial time and the processing of diagnostically relevant areas. The content analysis of verbal data was based on a categorisation system developed from the literature. RESULTS: Although experts and intermediates showed equal levels of diagnostic accuracy, their visual and cognitive processing differed. Whereas experts relied on their first findings and checked the image further for other abnormalities, intermediates tended to double-check their first findings. In their explanations, experts focused on the typicality of the tissue, whereas intermediates mainly mentioned many specific pathologies. Novices looked less often at the relevant areas and were incomplete, incorrect and inconclusive in their explanations. Their diagnostic accuracy was correspondingly poor. CONCLUSIONS: This study indicates that in the case of intermediates and experts, different visual and cognitive strategies can result in equal levels of diagnostic accuracy. Lessons for training underline the relevance of the distinction between normal and abnormal tissue for novices, especially when the mental rotation of 2-D images is required. Intermediates need to be trained to see deviations in abnormalities. Feedback and an educational design that is specific to these developmental stages might improve training.

Psychopathic-like traits in detained adolescents: clinical usefulness of self-report.

Studies have demonstrated that self-report tools can be used to reliably and validly examine psychopathic-like traits in adolescents. However, it is unclear if self-report instruments are still reliable and valid when confidentiality cannot be guaranteed, such as during routine assessments in juvenile detention centres. To address this issue, the current study used data from the routine mental health screening of 365 detained male adolescents (12-18 years) in two juvenile detention centres. With the intention of gaining insight in the clinical usefulness of self-reported psychopathic-like traits, we examined relations known from literature with emotional and behavioural features. Self-reported psychopathic-like traits, measured by the Youth Psychopathic Traits Inventory-Short version (YPI-S), were uniquely associated with substance abuse, anger/irritability, conduct problems and hyperactivity, but not with internalizing problems. YPI-S-dimensions showed several specific relationships with variables of interest. For example, only the callous unemotional dimension was negatively related with prosocial behaviour and only the behavioural dimension was positively related with hyperactivity. In conclusion, self-reported psychopathic-like traits showed expected relations with relevant variables. These findings suggest that self-report can be used to identify detained youths with high levels of psychopathic-like traits outside a research context, thus, even when anonymity and confidentiality are not guaranteed.

Relationships between interpersonal trauma, symptoms of posttraumatic stress disorder, and other mental health problems in girls in compulsory residential care.

This cross-sectional study examined the relationships (using structural equation modeling) between exposure to early-onset interpersonal trauma, symptoms of posttraumatic stress disorder (PTSD), symptoms of complex PTSD, and other mental health problems. The participants were 92 girls recruited from 3 residential treatment facilities. Exposure to early-onset interpersonal trauma was directly related to mental health problems and symptoms of PTSD mediated the relationship between exposure to early-onset interpersonal trauma and mental health problems. Symptoms of complex PTSD did not significantly mediate this relationship. These findings have direct implications for rehabilitation efforts in girls in compulsory residential care.

The dimensional structure of the functional abilities in cases of long-term sickness absence.

BACKGROUND: The health problems that working people suffer can affect their functional abilities and, consequently, can cause a mismatch between those abilities and the demands of the work, leading to sickness absence. A lasting decrease in functional abilities can lead to long-term sickness absence and work disability, with negative consequences for both the worker and the larger society. The objective of this study was to identify common disability characteristics among large groups of long-term sick-listed and disabled employees. METHODS: As part of the disability benefit entitlement procedure in the Netherlands, an insurance physician assesses the functional abilities of the claimant in a standardised form, known as the List of Functional Abilities (LFA), which consists of six sections containing a total of 106 items. For the purposes of this study, we compiled data from 50,931 assessments. These data were used in an exploratory factor analyses, and the results were then used to construct scales. The stability of dimensional structure of the LFA and of the internal consistency of the scales was studied using data from 80,968 assessments carried out earlier, under a slightly different legislation. RESULTS: Three separate factor analyses carried out on the functional abilities of five sections of the LFA resulted in 14 scale variables, and one extra scale variable was based on the items from the sixth section. The resulting scale variables showed Cronbach's Alphas ranging from 0.59 to 0.97, with the exception of one of 0.54. The dimensional structure of the LFA in the verification population differed in some aspects. The Cronbach's Alphas of the verification population ranged from 0.58 to 0.97, again with the exception of the same scale: Alpha = 0.49. CONCLUSION: The differences between the dimensional structures of the primary data and the earlier data we found in this study restrict the possibilities to generalise the results. The scales we constructed can be utilised to produce a compact description of the functional abilities of groups of claimants in the Netherlands. Moreover, the matching work demands can be used to identify jobs low on those demands as being the most accessible for the specific type of disabled employees, particularly severely disabled individuals.

Can self-reported disability assessment behaviour of insurance physicians be explained? Applying the ASE model.

BACKGROUND: Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers. METHODS: This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit. RESULTS: Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process. CONCLUSION: A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.

Infantile cortical hyperostosis (Caffey disease): a possible misdiagnosis as physical abuse.

Infantile cortical hyperostosis (Caffey disease) is a rare self-limiting inflammatory bony disease of early infancy. We report a 1-month-old Chinese boy with Caffey disease who presented with painful swelling over his shins bilaterally. Physical abuse was initially suspected, but the radiological findings of periosteal thickening over multiple bones (particularly the mandible), symmetrical involvement, diaphyseal involvement with sparing of the epiphysis, made Caffey disease a likely diagnosis. This report highlights that infantile cortical hyperostosis is an important differential diagnosis for children suspected of being abused, and clinicians should have a high index of suspicion to avoid misdiagnosis.

When only the real thing will do: junior medical students' learning from real patients.

OBJECTIVES: This study aimed to explore how medical students experience contacts with real patients and what they learn from them. METHODS: We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers. RESULTS: Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent. CONCLUSIONS: Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning.

Predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) during residential treatment.

This prospective study examines the predictive validity of the Dutch version of the Structured Assessment of Violence Risk in Youth (SAVRY) by examining relationships between SAVRY scores and various types of disruptive behavior during residential treatment. The SAVRY, a risk assessment instrument, was coded for 66 male adolescents on the basis of file information and interviews. The adolescents were referred to Rentray, a juvenile correctional and treatment facility, by the Dutch juvenile courts because of severe behavioral problems or serious offenses. Institutional infractions were retrieved from incident registration files, which included acts of physical violence, verbal threat, verbal abuse, and violation of institutional rules. The interrater reliability of the SAVRY scores was good. The predictive validity of the SAVRY for physical violence against persons was excellent (Risk Total: AUC=.80, r =.33; Summery Risk Rating: AUC =.86, r =.48). The SAVRY also had good predictive validity for violence against objects, verbal threats and violations of rules, but not for verbal abuse. Implications for assessment and management of violent behavior among adolescents in residential treatment are discussed.

Stereological estimates of the basal forebrain cell population in the rat, including neurons containing choline acetyltransferase, glutamic acid decarboxylase or phosphate-activated glutaminase and colocalizing vesicular glutamate transporters.

The basal forebrain (BF) plays an important role in modulating cortical activity and influencing attention, learning and memory. These activities are fulfilled importantly yet not entirely by cholinergic neurons. Noncholinergic neurons also contribute and comprise GABAergic neurons and other possibly glutamatergic neurons. The aim of the present study was to estimate the total number of cells in the BF of the rat and the proportions of that total represented by cholinergic, GABAergic and glutamatergic neurons. For this purpose, cells were counted using unbiased stereological methods within the medial septum, diagonal band, magnocellular preoptic nucleus, substantia innominata and globus pallidus in sections stained for Nissl substance and/or the neurotransmitter enzymes, choline acetyltransferase (ChAT), glutamic acid decarboxylase (GAD) or phosphate-activated glutaminase (PAG). In Nissl-stained sections, the total number of neurons in the BF was estimated as approximately 355,000 and the numbers of ChAT-immuno-positive (+) as approximately 22,000, GAD+ approximately 119,000 and PAG+ approximately 316,000, corresponding to approximately 5%, approximately 35% and approximately 90% of the total. Thus, of the large population of BF neurons, only a small proportion has the capacity to synthesize acetylcholine (ACh), one third to synthesize GABA and the vast majority to synthesize glutamate (Glu). Moreover, through the presence of PAG, a proportion of ACh- and GABA-synthesizing neurons also has the capacity to synthesize Glu. In sections dual fluorescent immunostained for vesicular transporters, vesicular glutamate transporter (VGluT) 3 and not VGluT2 was present in the cell bodies of most PAG+ and ChAT+ and half the GAD+ cells. Given previous results showing that VGluT2 and not VGluT3 was present in BF axon terminals and not colocalized with VAChT or VGAT, we conclude that the BF cell population influences cortical and subcortical regions through neurons which release ACh, GABA or Glu from their terminals but which in part can also synthesize and release Glu from their soma or dendrites.

Psychopathic traits and maltreatment: Relations with aggression and mental health problems in detained boys.

Psychopathic traits and a history of maltreatment are well-known risk factors for mental health problems and aggression. A better insight in the impact of such risk factors on juvenile delinquents is likely to help tailoring treatment. Therefore, this study aimed to examine mental health problems and aggression in detained delinquent youths with various levels of psychopathic traits and maltreatment. Standardized questionnaires were used to assign 439 detained male adolescents (N = 439; from 13 to 18years of age) to one of six mutually exclusive groups: adolescents with (1) low psychopathic traits without maltreatment; (2) low psychopathic traits and one type of maltreatment; (3) low psychopathic traits and multiple types of maltreatment; (4) high psychopathic traits without maltreatment; (5) high psychopathic traits and one type of maltreatment and finally (6) high psychopathic traits and multiple types of maltreatment. Next, groups were compared on mental health problems, mental disorders and reactive and proactive aggression. Findings indicated that compared to the low psychopathic traits groups, high psychopathic traits groups had markedly higher levels of externalizing mental health problems (such as attention deficit/hyperactivity, substance abuse, rule-breaking), proactive and reactive aggression, but not of internalizing mental health problems (anxiety and depression). Mental health problems in boys with a low level of psychopathic traits increased with the number of types of maltreatment in their history. In boys with a high level of psychopathic traits, group differences did not reach significance. Levels of proactive and reactive aggression increased with the number of types of maltreatment in boys with low levels of psychopathic traits, but not in those with high psychopathic traits. Thus, in detained adolescents both psychopathic traits and the number of maltreatment types are related to the severity of mental health problems and types of aggression. When used in routine screening procedures, these risk factors may thus improve identification and support targeted treatment-allocation of detained adolescents with serious clinical problems.

A prospective study on the risk of exposure to HIV during surgery in Zambia.

OBJECTIVE: To investigate the relative risk of occupational HIV transmission for surgeons practising in tropical Africa compared with their western colleagues. DESIGN AND SETTING: From June to November 1993, a prospective study was performed at St Francis' Hospital, Katete, Zambia (350-bed hospital which serves a community of 300,000 people). METHODS: The HIV seroprevalence among consecutive surgical patients and the incidence of occupational parenteral exposures to blood during surgery were prospectively studied in a Zambian district hospital. HIV seroprevalence was determined by taking blood from the surgical patients on admission into the operating theatre. Serum was stored at -20 degrees C and transported to the Academic Medical Centre of the University of Amsterdam, where the presence of HIV antibodies was tested by enzyme immunoassay and seropositive samples confirmed by Western blot. Number of parenteral exposures during the study period was scored by interviewing the seven surgeons and their personnel after each surgical procedure about accidental parenteral exposures to blood. The total number of parenteral exposures per surgeon per year was obtained by extrapolation. The cumulated risk of seroconversion due to parenteral blood exposure can be calculated as: 1-(1-fp)ny, where f is the population seroprevalence, p the chance of transmission per incident (estimated to be 0.46%), n the number of parenteral exposures per year and y the years of practice. RESULTS: HIV seroprevalence in the surgical patient group was 22.3%. Twelve parenteral exposures to blood (surgeons, n = 8; other personnel, n = 4) took place in 1161 operations. Number of parenteral exposures per surgeon was extrapolated to three per year. The non-dominant index finger was exposed in 10 out of the 12 parenteral exposures. Based on these data, the risk of contracting HIV infection for a surgeon practising in Zambia for 5 years is 1.5%. The risk for a surgeon working in a western hospital when f = 0.23%, n = 20 per year (5.6% of 350 operations) and y = 5 is estimated at 0.1%. CONCLUSIONS: Although occupational exposure rate was relatively low, the HIV seroprevalence was so high that the relative cumulated seroconversion risk for surgeons in tropical Africa is estimated to be 15 times higher than in western countries. This implies that health-care organizations should bear in mind that each year one out of 300 employees working in tropical Africa may become occupationally infected with HIV.

PIP: A prospective study conducted in 1993 at St Francis' Hospital in Katete, Zambia, indicated that the human immunodeficiency virus (HIV) seroconversion risk among surgeons in tropical Africa may be 15 times higher that in developed countries. During the six-month study period, surgeons recorded any parenteral blood exposure and serum samples from 296 patients randomly selected from the 1078 patients undergoing surgery in this period were analyzed; of these, 66 (22.3%) were HIV-positive. During the 1161 surgical procedures, there were 12 (1%) superficial parenteral exposures, four of which were found to involve HIV-infected blood. These exposures included 10 needle-sticks with a non-hollow suture needle, one hand laceration, and one splash to the eye. Half involved obstetricians/gynecologists. For a surgeon working in Zambia for five years, the risk of contracting HIV through parenteral exposure can--on the basis of this study--be calculated at 1.5% given a 22.3% patient seroprevalence rate and an average of three exposures per year (0.7% of 400 operations per year per surgeon). For a western surgeon, this risk is 0.1% (0.23% seroprevalence rate and 20 accidental injuries per year--5.6% of 350 operations). The lower number of parenteral exposures among Zambian surgeons reflects the lack of power tools in the tropics and the relative simplicity of surgical procedures. On the basis of these findings, it can be estimated that one in every 300 surgical employees in tropical Africa will become occupationally infected with HIV, and the risk of exposure can be expected to increase along with increases in HIV seroprevalence.

A simple method to microinject solid neural tracers into deep structures of the brain.

We have developed an instrument to perform microinjections of solid neural tracers into deep structures of the brain. The instrument consists of a thin hypodermic needle equipped with a movable internal rod, which is connected to a pressure chamber. When a pressure pulse is applied to the chamber, the rod moves forward and back inside the needle, pushing out a solid load previously packed inside the needle tip. By attaching a microelectrode to the instrument, it is also possible to have electrophysiological control of the injection placement. To test the instrument, we microinjected DiI and rhodamine crystals into selected structures of the visual system of pigeons. The results show small, well-defined injection sites, accurately located in the desired targets, together with well-developed anterogade and retrograde transport, selectively originated from the injection sites. This method extends the usage of solid tracers to most structures in the brain and may, in certain cases, be more advantageous than the conventional method of injecting tracer solutions.

Reversible mechanical fixation of eye position in awake head-restrained pigeons (Columba livia).

Here we describe a method to fix gaze positions and to significantly reduce saccadic oscillations in pigeons. The procedure consists of a mechanical immobilization of the eye through the use of an electromagnet that exerts a radial force upon a small metal rectangle glued to the dorsal part of the eye. The method can be used in avian visual neurophysiology in order to hold the eye immobilized for periods of time, long enough to map the properties of visual receptive fields and investigate the possible functions of saccadic oscillations.

A Qualitative Analysis of the Transition from Theory to Practice in Undergraduate Training in a PBL-Medical School.

In spite of numerous curricular innovations, the problems medical students encounter in making the transition from theoretical training to clinical training remain unresolved and the problem has received scant attention in the literature. We performed a qualitative study to explore students' perceptions and attitudes regarding this transition in undergraduate medical training. Twenty fifth-year students of the Maastricht Medical School participated in focus group discussions about the transition from the preclinical phase to the clinical phase of the curriculum. All focus group discussions were videotaped, literally transcribed and qualitatively analysed using content analysis. The results suggest that students have difficulty in bridging the gap between the theoretical and clinical phase of the curriculum. The problems they experience arise largely from professional socialisation processes. However, students also find it difficult to apply theoretical knowledge in clinical practice. Students find contacts with real patients highly motivating. In the clinical phase their learning changes from passive acquisition of knowledge to more active learning.Since the problem-based learning approach is supposed to enhance application of basic science concepts to clinical problems, it is surprising that students experience difficulties in applying their knowledge in practice. To facilitate the transition from theory to practice in the Maastricht Medical School some curricular changes could be introduced, such as early patient contacts to motivate students and help them learn usable knowledge. Furthermore, the advantages of a problem-based preclinical curriculum to student learning should be fully exploited. Finally, the assessment system must be congruent with the educational programme, because examinations have a powerful effect on student learning.

The robustness of medical expertise: clinical case processing by medical experts and subexperts.

Medical specialists confronted with problems in their domain of expertise do not rely on intentional causal reasoning, using explicit principles or rules. Rather, reasoning is an automatic process, using knowledge in an encapsulated mode. Less clear is what happens when medical specialists encounter problems outside their specialties. To shed light on this issue, we asked cardiologists and pulmonologists to evaluate 4 clinical cases, 2 in the domain of cardiology and 2 in pulmonology. Their task was to study, diagnose, recall, and explain the signs and symptoms of the clinical case descriptions. The cardiologists and pulmonologists alike processed cases in their specialties faster and more accurately, but recall and pathophysiological explanations did not reveal significant differences. These results suggest that medical specialists do not process cases outside their specialties in a qualitatively different mode from cases within their specialties.