An Update Summary on the Learning Sciences Within an Ophthalmic Context.

Clinical reasoning, specifically diagnostic decision-making, has been a subject of fragmented literature since the 1970s, marked by diverse theories and conflicting perspectives. This article reviews the latest evidence in medical education, drawing from scientific literature, to offer ophthalmologists insights into optimal strategies for personal learning and the education of others. It explores the historical development of clinical reasoning theories, emphasising the challenges in understanding how doctors formulate diagnoses. The importance of clinical reasoning is underscored by its role in making accurate diagnoses and preventing diagnostic errors. The article delves into the dual process theory, distinguishing between type 1 and type 2 thinking and their implications for clinical decision-making. Cognitive load theory is introduced as a crucial aspect, highlighting the limited capacity of working memory and its impact on the diagnostic process. The zone of proximal development (ZPD) is explored as a framework for optimal learning environments, emphasising the importance of scaffolding and deliberate practice in skill development. The article discusses semantic competence, mental representation, and the interplay of different memory stores-semantic, episodic, and procedural-in enhancing diagnostic proficiency. Self-regulated learning (SRL) is introduced as a student-centric approach, emphasising goal setting, metacognition, and continuous improvement. Practical advice is provided for minimising cognitive errors in clinical reasoning, applying dual process theory, and considering cognitive load theory in teaching. The relevance of deliberate practice in ophthalmology, especially in a rapidly evolving field, is emphasised for continuous learning and staying updated with advancements. The article concludes by highlighting the importance of clinical supervisors in recognising and supporting trainees' self-regulated learning and understanding the principles of various teaching and learning theories. Ultimately, a profound comprehension of the science behind clinical reasoning is deemed fundamental for ophthalmologists to deliver high-quality, evidence-based care and foster critical thinking skills in the dynamic landscape of ophthalmology.

Strategies for engaging patients in co-design of an intervention.

OBJECTIVE: We provide practical guidance about using co-design methods to collaborate with patients to create patient-facing interventions, which others can use when undertaking similar projects. METHODS: This is a narrative review synthesizing co-design principles and published literature with our experience working alongside five Veteran patients of the U.S. Department of Veterans Affairs in New England to co-design a portfolio of patient-facing materials to improve patient-centered care coordination. Our process took 12 weeks (April - June 2022) and was conducted entirely via video conference. RESULTS: Co-design is a participatory research method. Its principles include sharing power over the research process and products, agency for all participants, embracing a plurality of forms of knowledge, and mutual and reciprocal benefit. We describe three stages of the co-design process (preparatory work; design and development; feedback and closure), strategies and techniques we used at each stage, challenges we faced, and considerations for addressing them. CONCLUSION: Co-designing patient-facing interventions blends different forms of knowledge to produce practical, contextually specific interventions with ownership by the people who will use them. PRACTICE IMPLICATIONS: Co-design is a feasible methodology for most health services research teams whose goal is to intensify patient engagement in research.

Modifying Whole Health Services for Successful Telehealth Delivery: Lessons from Veterans Health Administration's Rapid Transition During the COVID-19 Pandemic.

Introduction: The Veterans Health Administration (VHA) is shifting care from a disease-oriented to health-creating approach that aims to provide whole person care. This Whole Health (WH) system combines person-centered care with delivery of WH services (e.g., health coaching, well-being education and skill-building classes, and evidence-based complementary and integrative health therapies), alongside conventional medical services. During the COVID-19 pandemic, WH services were modified for delivery through telehealth (teleWH). This article characterizes modifications to WH services made to maintain continuity during the transition to telehealth formats. Materials and methods: We conducted semistructured qualitative interviews with a purposive sample of 51 providers delivering teleWH services at 10 VHA medical centers. We examined WH service modifications as well as facilitators and barriers to those modifications using rapid coding and directed content analysis. Results: Modifications were driven by (1) preparing for teleWH service delivery and (2) improving teleWH service delivery. To prepare for teleWH services, modifications were prompted by access, readiness, and setting and resources. Modifications to improve the delivery of teleWH services were motivated by engagement, community-building, safety, and content for a teleWH environment. One-on-one teleWH services required the fewest modifications, while more significant modifications were needed for well-being, skill-building, and movement-based groups, and reconfiguration of manual therapies. Discussion: Findings highlighted the need for modifications to ensure that teleWH services are accessible and safe and support interpersonal relationships between patients and providers, as well as in group-based classes. Successfully delivering teleWH services requires proactive preparation that considers access, readiness, and the availability of resources to engage in teleWH services. Tailoring strategies and considering the unique needs of different teleWH services are critical. Conclusions: The COVID-19 pandemic catalyzed teleWH service implementation, utilization, and sustainment. The challenges faced and modifications made during this transition provide lessons learned for other health care systems as they attempt to implement teleWH services.

Optical coherence tomography angiography: a review of the current literature.

This narrative review presents a comprehensive examination of optical coherence tomography angiography (OCTA), a non-invasive retinal vascular imaging technology, as reported in the existing literature. Building on the coherence tomography principles of standard OCT, OCTA further delineates the retinal vascular system, thus offering an advanced alternative to conventional dye-based imaging. OCTA provides high-resolution visualisation of both the superficial and deep capillary networks, an achievement previously unattainable. However, image quality may be compromised by factors such as motion artefacts or media opacities, potentially limiting the utility of OCTA in certain patient cohorts. Despite these limitations, OCTA has various potential clinical applications in managing retinal and choroidal vascular diseases. Still, given its considerable cost implications relative to current modalities, further research is warranted to justify its broader application in clinical practice.

Pregnancy recommendations from women with intellectual and developmental disabilities to their peers.

BACKGROUND: As recent as the mid-twentieth century, eugenics practices on women with intellectual and developmental disabilities were commonplace. Deinstitutionalization has led to an increasing proportion of women with intellectual and developmental disabilities living in the community and becoming pregnant. Previous research has reported barriers to maternal health care (i.e., perceived provider stigma, inadequate communication, stress surrounding child protective services involvement, and financial strain). Research shows that this population is at increased risk of adverse outcomes including preterm delivery, low birth weight babies, and maternal mortality. OBJECTIVE/HYPOTHESIS: This study aimed to explore recommendations from mothers with intellectual and developmental disabilities for other women to potentially improve pregnancy experiences for this population. METHODS: We conducted semi-structured individual interviews among 16 women with intellectual and developmental disabilities. Data were coded using a content analysis process and iteratively analyzed using inductive and deductive techniques to determine emergent themes. RESULTS: Participants offered recommendations for navigating pregnancy to their peers who are pregnant, or thinking about becoming pregnant. Themes included: (1) planning for birth; (2) advocating at the point-of-care; (3) seeking supports and services; (4) interacting with child protective services; (5) communicating with providers; and (6) exhibiting resilience. CONCLUSION: Our study highlights recommendations for improving pregnancy experiences of women with intellectual and developmental disabilities. Informed by the lived pregnancy experiences of our participants, these recommendations can inform clinician training, new guidelines, and services to support and improve pregnancy experiences for women with intellectual and developmental disabilities.

Implementing Shared Decision-Making for Lung Cancer Screening across a Veterans Health Administration Hospital Network: A Hybrid Effectiveness-Implementation Study Protocol.

Shared decision-making (SDM) for lung cancer screening (LCS) is recommended by multiple organizations, reflecting a larger movement toward patient-centered care. Yet SDM for LCS does not routinely occur owing to barriers at multiple levels. Moreover, how best to implement SDM into routine clinical practice remains unknown. There is a need for a novel approach to overcome multilevel barriers and ensure high-quality SDM for LCS is integrated into routine practice. We present the protocol for our U.S. Department of Veterans Affairs (VA)-funded study. Our protocol is designed to implement and evaluate a multilevel, tailored approach to SDM for LCS in routine clinical practice within the VA New England Health Care Network, comprising eight medical centers. In this prospective, pragmatic hybrid implementation-effectiveness study, we will first conduct a formative evaluation of barriers to SDM for LCS at each level of the socioecological model, which will inform our tailored implementation plan. We will then sequentially introduce components of our tailored, multilevel approach to implementing SDM for LCS across VA New England. Finally, using mixed methods, we will evaluate the implementation and its impact on effectiveness (primary outcome, defined as patient-centeredness of SDM), as well as implementation outcomes informed by the RE-AIM implementation science framework (i.e., reach to patients, adoption by providers, implementation fidelity). Tailored implementation will address identified challenges to achieving policy recommendations for SDM for LCS in VA New England, inform nationwide implementation of SDM for LCS, and address stakeholder interests in promoting more patient-centered interactions across the VA.

Towards a framework for patient-centred care coordination: a scoping review protocol.

INTRODUCTION: Patient-centred care and care coordination are each key priority areas for delivering high quality healthcare. However, the intersection between these two concepts is poorly characterised. We theorise that greater advancements in healthcare quality could be realised when care is organised in a way that aligns with patients' preferences, needs and values across every level of the healthcare system. There is currently no published review that describes the intersection of patient-centred care and care coordination. We will undertake a scoping review that will be foundational to the development of a conceptual framework for patient-centred care coordination that integrates and synthesises the overlap between these two concepts and describe how it manifests across levels of the healthcare system. METHODS AND ANALYSIS: A multidisciplinary team of reviewers will conduct a scoping review of published and grey literature to identify and synthesise key concepts at the intersection of patient-centred care and care coordination, following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidance for scoping reviews. Databases we will use in our search include PubMed, CINAHL, Embase, Social Sciences Abstracts, Nursing and Allied Health Premium, Health and Medical Collection, and PsycINFO. Articles will be included that are English-language; published during or after 2001; describe a theory, conceptual model, theoretical framework or definition that addresses both patient-centred care and care coordination. Articles will be excluded if they do not address the intersection of patient-centred care and care coordination; discuss a patient-centred medical home without discussion on patient-centred care concepts; or discuss a paediatric, inpatient or palliative care setting. A data extraction template will facilitate qualitative thematic analysis and findings will be synthesised into a conceptual framework. ETHICS AND DISSEMINATION: This work does not require ethics approval. A preliminary framework will be presented to a group of patient stakeholders for refinement before dissemination through a peer-reviewed journal and conference presentations.

Promoting Whole Health and Well-Being at Home: Veteran and Provider Perspectives on the Impact of Tele-Whole Health Services.

Background: The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans' self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH). Objective: We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being. Methods: Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach. Results: We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being. Conclusion: Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.