Attending Physician Variability: A Model of Four Supervisory Styles

Purpose: There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. 

Method: Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. 

Results: Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. 

Conclusions: The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.

Thinking ‘Dignity’ as a basis towards inclusive development

In an era of increasing political disenfranchisement, deep economic inequalities and associated social humiliations encountered by the rapidly globalising planet, this paper seeks to chart the current thinking about the paths that civil society need to take in order to achieve distinctive peace. Here commitment as part of the universal cosmopolitan order is critical to go beyond the binaries of religious and cultural differences. The role of dignity, of interdependency, respect and understanding has become all the more critical to sustain hope and life in this age of austerity. The paper argues for an empowered citizenship, based on dignity and respect to think socially towards inclusive development.

Unsettling modernity: Shifting values and changing housing styles in the Kathmandu Valley

Abstract

Culture has always been important for the character of the cities, as have the civic and public institutions that sustain a lifestyle and provide an identity. Substantial evidence of the unique historical, urban civilisation remains within the traditional settlements in the Kathmandu Valley in Nepal; manifested in houses, palaces, temples, rest houses, open spaces, festivals, rituals, customs and cultural institutions. Indigenous knowledge and practices prescribed the arrangement of houses, roads and urban spaces giving the city a distinctive physical form, character and a unique oriental nativeness. In technical sense, these societies did not have written rules for guiding development. In recent decades, the urban culture of the city has been changing with the forces of urbanisation and globalisation and the demand for new buildings and spaces. New residential design is increasingly dominated by distinctive patterns of Western suburban ideal comprising detached or semi-detached homes and high rise tower blocks. This architectural iconoclasm can be construed as a rather crude response to the indigenous culture and built form. The paper attempts to dismantle the current tension between traditional and contemporary ‘culture’ (and hence society) and housing (or built form) in the Kathmandu Valley by engaging in a discussion that cuts across space, time and meaning of architecture as we know it.

Computational Thinking across a Life Course

Symposium of papers on Computational Thinking

Wishful Thinking: Lessons from the internal and external evaluations of an innovatory education project in Northern Ireland

From March 1999 to August 2000, the authors were involved in simultaneous internal and external evaluations of the social civic and political education (SCaPE) project in Northern Ireland. This project was a major initiative established by the Citizenship Foundation, the Northern Ireland Council for the Curriculum, Examination and Assessment (CCEA), and the School of Education at the University of Ulster at Coleraine. It was a 2-year project in 25 secondary schools established to design, develop, pilot and evaluate a new programme of social, civic and political education for Northern Ireland. It also aimed to serve as a model for future Citizenship curriculum developments throughout Northern Ireland and elsewhere. This paper describes the background to the project, the design and conduct of the two evaluations, and the links between them. It outlines the main conclusions of each evaluation and describes the way SCaPE has since evolved into a mainstream curriculum development project. The final part of the paper analyses the key opportunities, tensions and challenges involved in running such evaluations at a critical time in the history of Northern Ireland – a time when innovation is both necessary and controversial. It argues that, especially in such circumstances, evaluation cannot be conducted from a neutral, objective standpoint, and that it is incumbent on evaluators to recognise the emotional, personal and political commitment they make to the projects in which they are engaged.

Episodic Future Thinking in 4-Year-Olds, Poster Symposium: The who, what, where and when of episodic foresight development

The ability to project oneself into the future to pre-experience an event is referred to as episodic future thinking (Atance & O’Neill, 2001). Only a relatively small number of studies have attempted to measure this ability in pre-school aged children (Atance & Meltzoff, 2005; Busby & Suddendorf, 2005ab, 2010; Russell, Alexis, & Clayton, 2010).Perhaps the most successful method is that used by Russell et al (2010). In this task, 3- to 5-year-olds played a game of blow football on one end of a table. After this children were asked to select tools that would enable them to play the same game tomorrow from the opposite, unreachable, side of the table. Results indicated that only 5-year-olds were capable of selecting the right objects for future use more often than would be expected by chance. Above-chance performance was observed in this older group even though most children failed the task because there was a low probability of selecting the correct 2 objects from a choice of 6 by chance.This study aimed to identify the age at which children begin to consistently pass this type of task. Three different tasks were designed in which children played a game on one side of a table, and then were asked to choose a tool to play a similar game on the other side of the table the next day. For example, children used a toy fishing rod to catch magnetic fish on one side of the table; playing the same game from the other side of the table required a different type of fishing rod. At test, children chose between just 2 objects: the tool they had already used, which would not work on the other side, and a different tool that they had not used before but which was suitable for the other side of the table. Experiment 1: Forty-eight 4-year-olds (M = 53.6 months, SD = 2.9) took part. These children were assigned to one of two conditions: a control condition (present-self) where the key test questions were asked in the present tense and an experimental condition (future-self) where the questions were in the future tense. Surprisingly, the results showed that both groups of 4-year-olds selected the correct tool at above chance levels (Table 1 shows the mean number of correct answers out of three). However, the children could see the apparatus when they answered the test questions and so perhaps answered them correctly without imagining the future. Experiment 2: Twenty-four 4-year-olds (M = 53.7, SD = 3.1) participated. Pre-schoolers in this study experienced one condition: future-self looking-away. In this condition children were asked to turn their backs to the games when answering the test questions, which were in the future tense. Children again performed above chance levels on all three games.Contrary to the findings of Russell et al. (2010), our results suggest that episodic future thinking skills could be present in 4-year-olds, assuming that this is what is measured by the tasks. Table 1. Mean number of correct answers across the three games in Experiments 1 and 2Experimental Conditions (N=24 in each condition)Mean CorrectStandardDeviationStatistical SignificanceExp. 1 (present-self, look) – 2 items2.750.68p < 0.001Exp. 1 (future-self, look) – 2 items 2.790.42p < 0.001Exp. 2 (future-self, away) – 2 items 2.330.64p < 0.001Exp. 3 (future-self away) – 3 items1.210.98p = 0.157

The thinking doctor: clinical decision making in contemporary medicine

Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised.