Journal of evaluation in clinical practice
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One of the criticisms of the operational/diagnostic criteria, generalised since DSM-III, has been that they were shaped solely to achieve the best inter-peer reliability with no considerations for validity. This does not fully reflect reality since throughout the development of the criteria, there was an effort to define and fulfil some validity requirements. However, despite several attempts to create alternative diagnostic systems, there is still a widespread misunderstanding of the epistemological foundations that support this paradigm. ⋯ On the epistemological basis of these operational criteria (OC) the influence of Hempel has been widely discussed. However, the group from St. Louis and, also the DSM-III editors, never openly acknowledged his role and his contribution and revealed other influences such as other medical specialties (that used and validated several OC in the diagnosis of their diseases). On the other hand, contrary to what has often been mentioned there has been a continuous attempt to validate the OC since their conception. In the implementation and development of the operational paradigm, a more instrumental trend was followed, focused on utility, but with successive attempts to achieve realistic validity by searching for biological or psychological causality. The methodologies were initially expert-driven and gradually more data-driven and included some variables external to the construct itself, such as familial aggregation, diagnostic consistency over time, prognostic and other psychometric measures.
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Review
Dual process models of clinical reasoning: The central role of knowledge in diagnostic expertise.
Research on diagnostic reasoning has been conducted for fifty years or more. There is growing consensus that there are two distinct processes involved in human diagnostic reasoning: System 1, a rapid retrieval of possible diagnostic hypotheses, largely automatic and based to a large part on experiential knowledge, and System 2, a slower, analytical, conscious application of formal knowledge to arrive at a diagnostic conclusion. However, within this broad framework, controversy and disagreement abound. In particular, many authors have suggested that the root cause of diagnostic errors is cognitive biases originating in System 1 and propose that educating learners about the types of cognitive biases and their impact on diagnosis would have a major influence on error reduction. ⋯ The two processing modes are better understood as a consequence of the nature of the knowledge retrieved, not as independent processes.
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In the context of a major health crisis, health professionals must first compare patients' recovery prospects, thus giving priority to the goal of saving the greatest number of lives. ⋯ The authors' proposed protocol has advantages over the other two protocols due to its greater practicality and capacity to account for egalitarian and consequentialist principles simultaneously. It aims at saving as many lives as possible within the constraints of fairness. Furthermore, the proposed protocol avoids discrimination against people with disabilities without, at the same time, promoting discrimination against the elderly.
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Charters and Heitman have recently argued that epidemic status is lost once the disease becomes 'accepted into people's daily lives and routines, becoming endemic-domesticated-and accepted'. This is a normativist, subjectivist approach to epidemic classification; that is, it is both value-laden, and dependent on the attitudes of the population. In this article, we argue for an alternative approach: a value-dependent realist account of epidemic-status. ⋯ To frame the argument we draw from complexity theory, arguing that human populations can be viewed as complex systems, and epidemic-status as an emergent property of a complex system. We propose aggregating the normative standards relevant to labeling a disease as an epidemic, and use this as our indicator for both the beginning, and the end of epidemics. An epidemic ends, we argue, once the burden of disease drops below an objective but distinctly normative 'epidemic threshold'.
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Case Reports
The role of the lived body during the integration of the traumatic experience of the sternotomy scar: A case study.
Open heart surgery is a potentially traumatic experience for patients, thus posing a real risk to both the patient's physical and mental health as well as bodily integrity. All of these can greatly affect the emotional relationship to the sternotomy scar, the physical aspect of self-representation. Sternotomy scars mark patients for life, yet our knowledge of patients' subjective experiences is unknown. ⋯ Based on our study, it seems that the corporeal dimension of posttraumatic growth may develop after the traumatic experience of heart surgery, in which bodily intimacy with oneself and Significant Others plays a major role. In this case study, the objective reality of the heart as "sick" flesh and the "broken, pierced" bone (Körper), as well as the dissociation-and then its integration-of the lived, living body experience (Leib) are outlined. Our case study was analysed in the theoretical framework of phenomenology and psychoanalysis.