Clinical reasoning: The relative contribution of identification, interpretation and hypothesis errors to misdiagnosis

The aim of this study was to identify and describe the types of errors in clinical reasoning that contribute to poor diagnostic performance at different levels of medical training and experience. Three cohorts of subjects, second- and fourth- (final) year medical students and a group of general practitioners, completed a set of clinical reasoning problems. The responses of those whose scores fell below the 25th centile were analysed to establish the stage of the clinical reasoning process - identification of relevant information, interpretation or hypothesis generation - at which most errors occurred and whether this was dependent on problem difficulty and level of medical experience. Results indicate that hypothesis errors decrease as expertise increases but that identification and interpretation errors increase. This may be due to inappropriate use of pattern recognition or to failure of the knowledge base. Furthermore, although hypothesis errors increased in line with problem difficulty, identification and interpretation errors decreased. A possible explanation is that as problem difficulty increases, subjects at all levels of expertise are less able to differentiate between relevant and irrelevant clinical features and so give equal consideration to all information contained within a case. It is concluded that the development of clinical reasoning in medical students throughout the course of their pre-clinical and clinical education may be enhanced by both an analysis of the clinical reasoning process and a specific focus on each of the stages at which errors commonly occur.

The association between student characteristics and the development of clinical reasoning in a graduate-entry, PBL medical programme

This study sought to assess the extent to which the entry characteristics of students in a graduate-entry medical programme predict the subsequent development of clinical reasoning ability. Subjects comprised 290 students voluntarily recruited from three successive cohorts of the University of Queensland's MBBS Programme. Clinical reasoning was measured once a year over a period of three years using two methods, a set of 10 Clinical Reasoning Problems (CRPs) and the Diagnostic Thinking Inventory (DTI). Data on gender, age at entry into the programme, nature of primary degree, scores on selection criteria (written examination plus interview) and academic performance in the first two years of the programme were recorded for each student, and their association with clinical reasoning skill analysed using univariate and multivariate analysis. Univariate analysis indicated significant associations between CRP score, gender and primary degree with a significant but small association between DTI and interview score. Stage of progression through the programme was also an important predictor of performance on both indicators. Subsequent multivariate analysis suggested that female gender is a positive predictor of CRP score independently of the nature of a subject's primary degree and stage of progression through the programme, although these latter two variables are interdependent. Positive predictors of clinical reasoning skill are stage of progression through the MBBS programme, female gender and interview score. Although the nature of a student's primary degree is important in the early years of the programme, evidence suggests that by graduation differences between students' clinical reasoning skill due to this factor have been resolved.

The clinical reasoning characteristics of diagnostic experts

The aim of this study was to identify and describe the clinical reasoning characteristics of diagnostic experts. A group of 21 experienced general practitioners were asked to complete the Diagnostic Thinking Inventory (DTI) and a set of 10 clinical reasoning problems (CRPs) to evaluate their clinical reasoning. Both the DTI and the CRPs were scored, and the CRP response patterns of each GP examined in terms of the number and type of errors contained in them. Analysis of these data showed that six GPs were able to reach the correct diagnosis using significantly less clinical information than their colleagues. These GPs also made significantly fewer interpretation errors but scored lower on both the DTI and the CRPs. Additionally, this analysis showed that more than 20% of misdiagnoses occurred despite no errors being made in the identification and interpretation of relevant clinical information. These results indicate that these six GPs diagnose efficiently, effectively and accurately using relatively few clinical data and can therefore be classified as diagnostic experts. They also indicate that a major cause of misdiagnoses is failure to properly integrate clinical data. We suggest that increased emphasis on this step in the reasoning process should prove beneficial to the development of clinical reasoning skill in undergraduate medical students.

Assessing clinical reasoning: A method to monitor its development in a PBL curriculum

The aim of this study was to develop and trial a method to monitor the evolution of clinical reasoning in a PBL curriculum that is suitable for use in a large medical school. Termed Clinical Reasoning Problems (CRPs), it is based on the notion that clinical reasoning is dependent on the identification and correct interpretation of certain critical clinical features. Each problem consists of a clinical scenario comprising presentation, history and physical examination. Based on this information, subjects are asked to nominate the two most likely diagnoses and to list the clinical features that they considered in formulating their diagnoses, indicating whether these features supported or opposed the nominated diagnoses. Students at different levels of medical training completed a set of 10 CRPs as well as the Diagnostic Thinking Inventory, a self-reporting questionnaire designed to assess reasoning style. Responses were scored against those of a reference group of general practitioners. Results indicate that the CRPs are an easily administered, reliable and valid assessment of clinical reasoning, able to successfully monitor its development throughout medical training. Consequently, they can be employed to assess clinical reasoning skill in individual students and to evaluate the success of undergraduate medical schools in providing effective tuition in clinical reasoning.

Computational fluid dynamics simulations in aerosol and nucleation studies

Nucleation is the first step in the formation of a new phase inside a mother phase. Two main forms of nucleation can be distinguished. In homogeneous nucleation, the new phase is formed in a uniform substance. In heterogeneous nucleation, on the other hand, the new phase emerges on a pre-existing surface (nucleation site). Nucleation is the source of about 30% of all atmospheric aerosol which in turn has noticeable health effects and a significant impact on climate. Nucleation can be observed in the atmosphere, studied experimentally in the laboratory and is the subject of ongoing theoretical research. This thesis attempts to be a link between experiment and theory. By comparing simulation results to experimental data, the aim is to (i) better understand the experiments and (ii) determine where the theory needs improvement. Computational fluid dynamics (CFD) tools were used to simulate homogeneous onecomponent nucleation of n-alcohols in argon and helium as carrier gases, homogeneous nucleation in the water-sulfuric acid-system, and heterogeneous nucleation of water vapor on silver particles. In the nucleation of n-alcohols, vapor depletion, carrier gas effect and carrier gas pressure effect were evaluated, with a special focus on the pressure effect whose dependence on vapor and carrier gas properties could be specified. The investigation of nucleation in the water-sulfuric acid-system included a thorough analysis of the experimental setup, determining flow conditions, vapor losses, and nucleation zone. Experimental nucleation rates were compared to various theoretical approaches. We found that none of the considered theoretical descriptions of nucleation captured the role of water in the process at all relative humidities. Heterogeneous nucleation was studied in the activation of silver particles in a TSI 3785 particle counter which uses water as its working fluid. The role of the contact angle was investigated and the influence of incoming particle concentrations and homogeneous nucleation on counting efficiency determined.

Unsteady MHD mixed convection flow over an impulsively stretched permeable vertical surface in a quiescent fluid

The unsteady mixed convection flow of an incompressible laminar electrically conducting fluid over an impulsively stretched permeable vertical surface in an unbounded quiescent fluid in the presence of a transverse magnetic field has been investigated. At the same time, the surface temperature is suddenly increased from the surrounding fluid temperature or a constant heat flux is suddenly imposed on the surface. The problem is formulated in such a way that for small time it is governed by Rayleigh type of equation and for large time by Crane type of equation. The non-linear coupled parabolic partial differential equations governing the unsteady mixed convection flow under boundary layer approximations have been solved analytically by using the homotopy analysis method as well as numerically by an implicit finite difference scheme. The local skin friction coefficient and the local Nusselt number are found to decrease rapidly with time in a small time interval and they tend to steady-state values for t* >= 5. They also increase with the buoyancy force and suction, but decrease with injection rate. The local skin friction coefficient increases with the magnetic field, but the local Nusselt number decreases. There is a smooth transition from the unsteady state to the steady state. (C) 2010 Elsevier Ltd. All rights reserved.

Terahertz wave characteristics of a single-walled carbon nanotube containing a fluid flow using the nonlocal Timoshenko beam model

This paper presents the effect of nonlocal scaling parameter on the terahertz wave propagation in fluid filled single walled carbon nanotubes (SWCNTs). The SWCNT is modeled as a Timoshenko beam,including rotary inertia and transverse shear deformation by considering the nonlocal scale effects. A uniform fluid velocity of 1000 m/s is assumed. The analysis shows that, for a fluid filled SWCNT, the wavenumbers of flexural and shear waves will increase and the corresponding wave speeds will decrease as compared to an empty SWCNT. The nonlocal scale parameter introduces certain band gap region in both flexural and shear wave mode where no wave propagation occurs. This is manifested in the wavenumber plots as the region where the wavenumber tends to infinite (or wave speed tends to zero). The frequency at which this phenomenon occurs is called the ``escape frequency''. The effect of fluid density on the terahertz wave propagation in SWCNT is also studied and the analysis shows that as the fluid becomes denser, the wave speeds will decrease. The escape frequency decreases with increase in nonlocal scaling parameter, for both wave modes. We also show that the effect of fluid density and velocity are negligible on the escape frequencies of flexural and shear wave modes. (C) 2010 Elsevier B.V. All rights reserved.

Structural studies of decaying fluid turbulence: Effect of initial conditions

We present results from a systematic numerical study of structural properties of an unforced, incompressible, homogeneous, and isotropic three-dimensional turbulent fluid with an initial energy spectrum that develops a cascade of kinetic energy to large wave numbers. The results are compared with those from a recently studied set of power-law initial energy spectra [C. Kalelkar and R. Pandit, Phys. Rev. E 69, 046304 (2004)] which do not exhibit such a cascade. Differences are exhibited in plots of vorticity isosurfaces, the temporal evolution of the kinetic energy-dissipation rate, and the rates of production of the mean enstrophy along the principal axes of the strain-rate tensor. A crossover between "non-cascade-type" and "cascade-type" behavior is shown numerically for a specific set of initial energy spectra.

The oscillation of a spheroid along its axis in a non-Newtonian fluid

The present paper investigates the nature of the fluid flow when a spheroid is suspended in an infinitely extending elastico-viscous fluid defined by the constitutive equations given by Oldroyd or Rivlin and Ericksen, and is made to perform small amplitude oscillations along its axis. The solution of the vector wave equation is expressed in terms of the solution of the corresponding scalar wave equation, without the use of Heine's function or spheroidal wave functions. Two special cases (i) a sphere and (ii) a spheroid of small ellipticity, are studied in detail.

Steady flow of a maxwell fluid in a porous cylindrical annulus with circular cross-section

When a fluid with memory is injected into any flow region some assumptions regarding the initial state of stress have to be made in order to determine the state of stress at any subsequent instant. For a Maxwell fluid, it is assumed that the fluid near the surface of injection is suddenly stressed and responds by starting flow in accordance with the mechanical model chosen. The flow of a Maxwell fluid with a single relaxation time has been determined under the above assumption in the following two cases: (i) annulus between two porous concentric circular cylinders, and (ii) space between two porous and infinitely extending parallel plates. The nature of flow in the present case is similar to that of the Reiner-Rivlin fluids obtained by Narasimhan2).

Slow rotation of a sphere in a non-Newtonian fluid with or without suction or injection

The flow generated by the rotation of a sphere in an infinitely extending fluid has recently been studied by Goldshtik. The corresponding problem for non-Newtonian Reiner-Rivlin fluids has been studied by Datta. Bhatnagar and Rajeswari have studied the secondary flow between two concentric spheres rotating about an axis in the non-Newtonian fluids. This last investigation was further generalised by Rajeswari to include the effects of small radial suction or injection. In Part A of the present investigation, we have studied the secondary flow generated by the slow rotation of a single sphere in non-Newtonian fluid obeying the Rivlin-Ericksen constitutive equation. In Part B, the effects of small suction or injection have been studied which is applied in an arbitrary direction at the surface of the sphere. In the absence of suction or injection, the secondary flow for small values of the visco-elastic parameter is similar to that of Newtonian fluids with inclusion of inertia terms in the Oseen approximation. If this parameter exceeds Kc = 18R/219, whereR is the Reynolds number, the breaking of the flow field takes place into two domains, in one of which the stream lines form closed loops. For still higher values of this parameter, the complete reversal of the sense of the flow takes place. When suction or injection is included, the breaking of the flow persists under certain condition investigated in this paper. When this condition is broken, the breaking of the flow is obliterated.

Flow of an electrically conducting non-newtonian fluid between two rotating coaxial cones in the presence of external magnetic field due to an axial current

Bhatnagar and Rathna (Quar. Journ. Mech. Appl. Maths., 1963,16, 329) investigated the flows of Newtonian, Reiner-Rivlin and Rivlin-Ericksen fluids between two rotating coaxial cones. In case of the last two types of fluids, they predicted the breaking of secondary flow field in any meridian plane. We find that such breaking is avoided by the application of a sufficiently strong azimuthal magnetic field arising from a line current along the axis of the cones.