Clinical risk and collective competence in the hospital emergency department in the UK.

The hospital emergency department (ED) is a risky environment, often subject to litigation for negligence. Risk is defined as an avoidable increase in the probability of an adverse outcome for a patient. With the aim of identifying the sources of risk, this study carried out participant observation and collected critical incidents in two EDs in the UK for a period of 30 months. Active failures included delay in beginning investigations or treatment, failure to obtain diagnostic information, misinterpretation of diagnostic information and the administration of inappropriate treatment. Three latent conditions underlay these failures: patients' unrestricted access to the ED, cognitive errors by individual members of staff and a strict horizontal and vertical division of labour. An analysis of the incidents resulting from the third latent condition identified a contradiction between the division of labour and working conditions in the ED. The paradigm circumstances under which this contradiction can result in active failures are described. The management of risks arising in this way could be improved by developing a workplace culture in which 'sapiential authority'--authority derived from experience, special access to information or being at hand in an emergency--is recognised in addition to authority derived from a formal status. However, as long the contradictions between the division of labour and working conditions remain, accidents should be considered normal events.

Medical students' errors in pharmacotherapeutics.

OBJECTIVES: This study analysed the errors made by 16 final-year medical students in a classroom prescribing exercise. The aim was to gain greater understanding of the reasons for non-optimal prescribing and of how to improve basic training in pharmacotherapeutics. METHODS: The task was to adjust a patient's phenytoin sodium dosage to achieve better control of seizures. It was based on a real-life case, and was presented as a written exercise. Process-tracing and think-aloud techniques were used to study the students' performance. RESULTS: The results suggest that the root cause of the errors was lack of a knowledge base which integrated scientific knowledge with clinical know-how. Three different clinical reasoning strategies were observed. Students who followed an incremental strategy demonstrated superior scientific knowledge and this resulted in less hazardous errors. Those who followed gambling or backward-reasoning strategies appeared to possess inferior scientific knowledge and this resulted in more hazardous errors. CONCLUSIONS: The results support current trends towards integrating basic medical science into a foundation of clinical know-how, as in the problem-based curriculum. They also emphasize the importance of a thorough grounding in medical science as a means of minimizing error.

The dangerous practice of thinking.

Information processing theory views thinking as the adaptation of activity to environmental inputs. A dual cognitive structure is proposed to explain this adaptation, in which thoughts are selected by interactions between an explicit memory system (accessible to consciousness) and an implicit memory system (inaccessible to consciousness). Contrary to commonsense assumptions about cognition, the implicit system plays the dominant role in skilled thinking. The explicit system has a largely regulatory function, overriding the implicit system when it encounters novel situations for which it has no response. Although the explicit system may be developed by cognitive process instruction in the classroom, the all-important implicit system is developed mainly by direct experience of the work environment independently of conscious information processing. Paradoxically, there are no grounds for declaring any part of medical science irrelevant to practical decision-making, as its effects on implicit memory are unknown. Nevertheless, it should be taught as the basis for regulating a process of thinking that is mainly implicit.

Modelling medical decision-making under uncertainty.

This study investigates the heuristic knowledge which underlies expertise in a medical decision-making task. Data are obtained from a process tracing study of a consultant physician. A production system is developed to simulate his decision-making, tested on new cases, and compared with the performance of a second consultant physician and a representative sample of medical students. The results indicate that the production system performs at an effective level, and that representing expertise in such terms would make this difficult task more tractable for learners.

Can past academic criteria predict students at risk of future failure?

A significant minority of medical and dental students fail their undergraduate courses. Early warning systems (EWSs) have been developed in some areas of higher education to predict 'at-risk' students at an early remedial stage. An attempt is made to develop an EWS to predict failure in the bacteriology component of the Batchelor of Dental Surgery course at Manchester Dental School. A system based on class tests and previous end-of-year performance is derived which is used to predict those students likely to fail or fall in the bottom 20-25% in their finals examination. The predictors are combined by a simple equal weights method, which is found to have the same predictive power as using multiple regression. Failure was correctly predicted in 60% of cases, at the expense of 71% false alarms. The high number of false alarms reflects the low failure rate rather than the lack of predictive information. The need for effective cross-validation of EWSs is discussed; many previous studies have not been tested on independent data.

A theoretical framework for improving education in geriatric medicine.

Alternative concepts of learning include a formal system in which part of the medical curriculum is designated as that for geriatric medicine; a non-formal system including conferences, lectures, broadcasts, available to both medical students and physicians; and thirdly, an informal system in which doctors learn medicine through their experience practising the profession. While the most emphasis in medical schools would seem to be on the formal system it is essential that medical educators (if they wish their students in later life to maintain high levels of self-initiated learning) must use all three strategies. The structure of a system of formal teaching for geriatric medicine is examined. An important objective is attitude change and it is in achieving this that geriatricians must be particularly involved in non-formal and informal systems.

Theoretical versus practical orientations in pre-clinical biochemistry teaching.

A pre-clinical lecture on the relevance of biochemical theory to clinical practice may adopt either a theoretical or a practical orientation. These two approaches were compared in an experiment involving seventy-one second-year medical students. Theory-orientated teaching was superior for promoting recall, while neither method showed overall superiority for promoting application. These results suggest hypotheses for future research.