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PubMed2001

New Evidence for Distinct Right and Left Brain Systems for Deductive versus Probabilistic Reasoning.

Deductive and probabilistic reasoning are central to cognition but the functional neuroanatomy underlying them is poorly understood. The present study contrasted these two kinds of reasoning via positron emission tomography. Relying on changes in instruction and psychological 'set', deductive versus probabilistic reasoning was induced using identical stimuli. The stimuli were arguments in propositional calculus not readily solved via mental diagrams. Probabilistic reasoning activated mostly left brain areas whereas deductive activated mostly right. Deduction activated areas near right brain homologues of left language areas in middle temporal lobe, inferior frontal cortex and basal ganglia, as well as right amygdala, but not spatial-visual areas. Right hemisphere activations in the deduction task cannot be explained by spill-over from overtaxed, left language areas. Probabilistic reasoning was mostly associated with left hemispheric areas in inferior frontal, posterior cingulate, parahippocampal, medial temporal, and superior and medial prefrontal cortices. The foregoing regions are implicated in recalling and evaluating a range of world knowledge, operations required during probabilistic thought. The findings confirm that deduction and induction are distinct processes, consistent with psychological theories enforcing their partial separation. The results also suggest that, except for statement decoding, deduction is largely independent of language, and that some forms of logical thinking are non-diagrammatic.

Adult↗
PubMed1999

Reasons for non-guideline-based antibiotic prescriptions for acute otitis media in The Netherlands.

BACKGROUND: Appropriate use of antibiotics is a major issue in today's medicine. The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally. It is known that overuse of antibiotics for upper respiratory tract infections exists. Little is known about the reasons for actual prescribing of antibiotics. In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, insight into the reasons for the actual prescribing could be important. OBJECTIVE: We aimed to explore the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media. METHOD: Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch GPs, were evaluated to see whether they followed the guidelines on acute otitis media of the Dutch College of General Practitioners. Non-guideline-based antibiotic prescriptions were discussed in stimulated recall interviews with the prescribing GPs regarding their prescribing behaviour of antibiotics for acute otitis media. RESULTS: In total, 77% of the antibiotic prescriptions did not follow the guidelines of the Dutch College of General Practitioners. Medical reasons for prescribing antibiotics were mentioned most often for non-guideline-based antibiotic prescriptions; however, in a substantial number of cases doctors gave non-medical reasons as well. CONCLUSIONS: Appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.

Acute Disease↗
PubMed2004

Teenagers and their family practitioner: matching between their reasons for encounter.

OBJECTIVES: The aim of this study was to analyse the reasons for encounter of teenagers in family practice and to compare them with the reasons recorded by their family practitioner (FP). METHODS: This cross-sectional study involved 91 FPs from the Paris area and from the French-speaking part of Belgium. The teenagers (12-17 years old) filled in an auto-administered questionnaire in the waiting room of their FP during a 1-week period. The doctor independently filled in a similar form after the consultation. Both questionnaires were matched afterwards to assess the concordance between the reasons for encounter recorded by the young patient and by his/her FP. RESULTS: More than 100 reasons for encounter were given by 457 teenagers. The majority of the complaints were respiratory (26%), general health (18.5%), osteoarticular (15%), digestive (11%) and neurological problems (9.5%). Gender did not influence the nature of the complaints, but age played a role. The older teenagers had more respiratory complaints, general and pregnancy/contraception problems. In 80% of the cases, the ailments listed by the teenagers were picked up by the practitioner. In 18% of the consultations, the FP recorded problems that had not been noted by the patient. CONCLUSION: Many common and a few serious although frequent youth problems were found among the reasons for encounter. Most of them were recorded by the practitioner. Time and communication skills are important to give the opportunity to the teenager to share sensitive topics with his/her FP.

Adolescent↗
PubMed1991

Empiric antibiotic selection by physicians: evaluation of reasoning strategies.

The objectives of the study were to evaluate the appropriateness of empiric antibiotic selection by housestaff treating medical patients with bacteremia. The design was a prospective, observational study at a university-affiliated hospital. Seventy-eight patients with bacteremia were evaluated. A clinical grade of acceptable or not acceptable was assigned to each antibiotic prescription by a consensus panel. The consensus panel found that 34.6% of antibiotic prescriptions were unacceptable (clinical grade). At least one flaw in the chain of reasoning was found in 56.4% of the 78 cases evaluated. Assessment of the clinical setting was correct in 94.9% of the cases; the portal of entry was identified in 91%; adequate knowledge of the bacterial flora at the suspected site of infection was found in 69%; the diagnostic workup was appropriate in 81%, and the correct antibiotic susceptibility patterns were given in 72%. A correct chain of reasoning was more likely to result in an acceptable clinical grade than flawed reasoning (p less than 0.005). However, an appropriate antibiotic selection was made by some physicians despite flawed reasoning, and inappropriate antibiotic selection occurred in a few cases despite fautless reasoning. In 3.8% of cases, unexpected organisms appeared in blood culture. Prescription of broad spectrum antibiotics may then be learned response. If so, educational efforts that emphasize narrow, rather than broad spectrum prescribing may be inadequate to change physician prescribing habits.

Anti-Bacterial Agents↗
PubMed1993

Teaching medical ethics to first-year students by using film discussion to develop their moral reasoning.

PURPOSE: To evaluate a project on teaching medical ethics to first-year students by using film discussion to develop the students' moral reasoning. METHOD: The participants were 114 first-year students at Texas A&M University Health Science Center College of Medicine in 1989-90, 1990-91, and 1991-92: (1) 48 (20 women and 28 men) who participated during the fall quarter in an elective course on social issues in medicine, which consisted of weekly one-hour discussions of short films; (2) 37 (18 women and 19 men) who participated in the course during both the fall and winter quarters; and (3) a control group of 29 (8 women and 21 men) who did not take the course and so had no exposure to the film discussions. The influence of the discussions on the students' moral reasoning was measured by using Rest's Defining Issues Test for pretests and posttests. The scores of the three groups were compared by using multivariate analysis of variance. RESULTS: There were statistically significant increases in the moral reasoning scores of both the course registrants with one-quarter exposure to the film discussions (p < .002) and those with two-quarter exposure (p < .008) compared with the scores of the students who did not take the course and had no exposure (p < .109). CONCLUSION: No doubt there was a self-selecting bias on the part of the course registrants; however, since both groups of registrants showed significant increases on their posttest scores, clearly the course did have a positive influence on these students' moral reasoning. Thus, it is possible to develop young people's moral reasoning in medical school as well as in earlier educational environments.

Control Groups↗
PubMed1998

The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students.

PURPOSE: To examine how much exposure to small-group case-study discussion is necessary to significantly increase moral reasoning skills. METHOD: For the classes of 1991-1998 at Texas A&M, using Rest's Defining Issues Test, the authors tested groups of students for moral reasoning skills both before and after the students participated in small-group case-study discussions of medical ethics. RESULTS: From 960 students asked to participate, the authors collected complete data for 729 students (75.9% response rate). Small-group case-study exposures ranged from 0 to 44 hours. Groups of students exposed to 20 hours or more demonstrated a significant increase in their moral reasoning scores. Groups with less than 20 hours of exposure demonstrated no significant increase in their scores. CONCLUSION: This study indicates that moral reasoning skills are teachable and measurable, and that small-group discussion significantly increases moral reasoning skills. Further studies are needed to increase the generalizability of these findings.

Education, Medical, Undergraduate↗
PubMed2002

HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing.

OBJECTIVES: We determined proportions of high-risk persons tested for HIV, the reasons for testing and not testing, and attitudes and perceptions regarding HIV testing, information that is critical for planning prevention programs. METHODS: Cross-sectional interview study of persons at high risk for HIV infection (men who have sex with men [MSM]; injection drug users [IDUs]; and heterosexual persons recruited from gay bars, street outreach, and sexually transmitted disease clinics) among six states participating in the HIV Testing Survey (HITS) in 1995 to 1996 (HITS-I) and 1998 to 1999 (HITS-II). RESULTS: Overall testing rates were lower in the HITS-I (1226/1599 [77%]) than in the HITS-II (1375/1711 [80%]) (p =.01). Persons <25 years old tested less frequently than those >or=25 years old (HITS-I: 71% vs. 78%, respectively, p=.007; HITS-II: 63% vs. 85%, respectively, p<.001). The main reasons for testing and not testing were the same in both surveys, but the proportions of reasons for not testing differed (e.g., "unlikely exposed to HIV" [HITS-I (17%) vs. HITS-II (30%), p<.0001], "afraid of finding out HIV-positive" [HITS-I (27%) vs. HITS-II (18%), p<.0001]). Attitudes regarding HIV testing differed among tested and untested respondents, especially among MSM. CONCLUSIONS: HIV testing rates were higher in the HITS-II, but testing rates decreased among the youngest respondents. Denial of HIV risk factors and fear of being HIV-positive were the principal reasons for not being tested. Availability of new HIV therapies may have contributed to decreased fear of finding out that one is HIV infected as a reason to avoid testing. The increased proportion of persons at risk who did not test because they believed they were unlikely to have been exposed highlights the need for prevention efforts to address risk perceptions.

AIDS Serodiagnosis↗
PubMed2004

Handling interaction in fuzzy production rule reasoning.

When fuzzy production rules are used to approximate reasoning, interaction exists among rules that have the same consequent. Due to this interaction, the weighted average model frequently used in approximate reasoning does not work well in many real-world problems. In order to model and handle this interaction, this paper proposes to use a nonadditive nonnegative set function to replace the weights assigned to rules having the same consequent, and to draw the reasoning conclusion based on an integral with respect to the nonadditive nonnegative set function, rather than on the weighted average model. Handling interaction in fuzzy production rule reasoning in this way can lead to a good understanding of the rules base and an improvement of reasoning accuracy. This paper also investigates how to determine from data the nonadditive set function that cannot be specified by a domain expert.

Algorithms↗
PubMedDate not supplied

Motivated scientific reasoning biases, epistemological beliefs, and theory polarization: a two-process approach to adolescent cognition.

Theory-motivated reasoning biases arise when different reasoning skills are invoked to evaluate evidence that is congruent or incongruent with individuals' belief systems. To explore this phenomenon, 66 early and 73 middle adolescents evaluated evidence relevant to their theories of social class or religion. In both conditions, reasoning biases were found, but in-group biases were evident only in the religion condition. In both conditions, higher order scientific reasoning was used to reject theory-incongruent evidence and judgmental heuristics (i.e., cognitive rules of thumb) were used to evaluate theory-congruent evidence. In both conditions, subsequent to the evidence presentation, adolescents' theories became more extreme (i.e., polarized) than at the outset of the experiment. Beliefs regarding the origin, acquisition, and certainty of knowledge, however, appeared to moderate reasoning biases and theory polarization. Age differences emerged on only one index of bias: In the religion condition, middle adolescents were more likely to treat theory-incongruent evidence as implausible. These findings are pertinent to theories of cognitive development, decision making, rationality, and in-group favoritism.

Adolescent↗
PubMed2004

Stroke prevention and atrial fibrillation: reasons leading to an inappropriate management. Main results of the SAFE II study.

AIMS: The aim of the Stroke and Atrial Fibrillation Ensemble (SAFE) II study was to identify the reasons underlying the under-utilization of oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (NVAF). METHODS: We investigated from all available sources the reasons why patients hospitalized for a stroke, who had a previously known NVAF, were not receiving OAC beforehand. We interviewed general practitioners (GPs) and cardiologists with a structured questionnaire, to identify the reasons for their therapeutic choice. RESULTS: Of 370 patients, 257 were theoretically eligible for OAC according to guidelines and the presence of contra-indications, but only 82 (22.2%) of them had actually received OAC before. We found that factors independently associated with the prescription of OAC were being followed-up by a cardiologist and having a younger GP. The leading reason evoked by GPs or cardiologists to explain why patients were not treated with OAC was the presence of a 'potential contra-indication', which was often inappropriate, followed by 'there was no indication', 'low compliance' and 'fear of bleeding'. CONCLUSIONS: An important reason for not prescribing OAC was the lack of knowledge about trials and guidelines. Medical education about OAC in NVAF should therefore be improved.

Aged↗
PubMed1992

Diagnostic reasoning among second-year nursing students.

This paper reports on a study investigating the relationship of nursing students' approaches to learning and processing of information, science content knowledge, ability in interpreting and organizing clinical data (nursing assessment), and logical reasoning ability with the accuracy and quality of the nursing diagnosis made in a simulated diagnostic reasoning task. One hundred and sixty-nine second-year pre-service nursing students participated in the study. Results of path analyses indicated a set of pathways from surface approach to low-quality nursing diagnosis that reflected less competent diagnostic reasoning; and a second set from deep/achieving approach through content knowledge and logical reasoning to higher-quality nursing diagnosis that reflected more competent diagnostic reasoning. The implications of these findings for nurse education are discussed.

Adolescent↗
PubMed2004

Supporting the problem-based learning process in the clinical years: evaluation of an online Clinical Reasoning Guide.

PURPOSE: Implementing problem-based learning (PBL) in the clinical years of a medical degree presents particular challenges. This study investigated the effectiveness of using an online Clinical Reasoning Guide to assist integration of PBL in the clinical setting and promote further development of students' clinical reasoning abilities. METHOD: A total of 52 students in 6 PBL groups, together with their 6 clinical tutors, participated in the study. Data were analysed from videotaped observations of tutorial activity and follow-up, semistructured interviews. RESULTS: From both the student facilitators' and the clinical tutors' perspectives, the Guide proved an effective tool for augmenting the PBL process in clinical settings and promoting the development of clinical reasoning. By combining computer-aided learning with collaborative PBL tutorials it promoted individual as well as collaborative reasoning. There is also evidence to suggest that the Guide prompted students to look more critically at their own, their colleagues' and other clinicians' reasoning processes.

Clinical Competence↗
PubMed2005

What every teacher needs to know about clinical reasoning.

CONTEXT: One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. PURPOSE: The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. DISCUSSION: Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.

Clinical Competence↗
PubMed2005

Research in clinical reasoning: past history and current trends.

BACKGROUND: Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory. PURPOSE: This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill--the "clinical reasoning" process; (b) research based on probes of memory--reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations--semantic qualifiers, scripts, schemas and exemplars. RESULTS AND CONCLUSIONS: Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy. IMPLICATIONS: It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.

Clinical Competence↗
PubMed1995

Moral reasoning about sexually transmitted diseases.

The purpose of this research was to investigate moral reasoning related to sexual behavior that could lead to the transmission of sexually transmitted diseases (STDs). Using hypothetical dilemmas about situations in which STDs can be transmitted, respondents were asked to explain why they believed the characters should or should not engage in risky behaviors. 40 college freshmen (M = 18.3 years) and 32 college seniors (M = 22.3 years) participated. Using Kohlberg's moral stage theory and Gilligan's moral orientation model, the interviews were scored for moral stage and moral orientation. Results indicated that the older age group had a significantly higher stage of moral reasoning than the younger age group when responding to dilemmas about STDs. There was a significant difference in moral stage between dilemmas, reflecting the possible effect of dilemma content on moral reasoning. The overall pattern of results shows nonsignificant gender differences in stage of moral reasoning and moral orientation. Clinical and theoretical implications of these findings for understanding the role of moral reasoning in sexual risky behavior are discussed.

Adolescent↗
PubMed1995

Women's reasons for not seeking prenatal care: racial and ethnic factors.

Our objective was to determine if there were differences in the reasons for not seeking early prenatal care among low-income black, Hispanic, and white women who had four or fewer prenatal care visits or care only in the third trimester, and who gave birth at Denver General Hospital in Colorado. Data were gathered from 606 women (48% Hispanic, 26% black, 26% white) after delivery, using a 188-item questionnaire and abstracted medical charts. The most important reasons for not seeking early prenatal care were attitudinal (47%), financial (26%), and structural and system problems (8.5%). Financial reasons were more important to white than to black or Hispanic women, and attitudinal reasons were more important to black and Hispanic than to white women. The analysis showed that education and marital status were sometimes confounding variables. Clear differences in reasons for not seeking prenatal care were reported by women of dissimilar racial and ethnic groups in this public hospital. Cultural variations in women's views should be taken into account in developing programs intended to improve prenatal care and pregnancy outcome in Denver.

Adult↗
PubMed1992

Reasons preventing regular dental care.

The aim was to determine what reasons restrict people's daily cleaning of their teeth and yearly attendance for a dental check-up, using as a theoretical background the ideas of Eichholz & Rogers on the rejection of innovation. The series consisted of young and middle-aged persons, 207 women and 183 men, who filled in a questionnaire on the above topics. The questions were phrased so as to cover different reasons for rejecting innovations. Factors analysis revealed the following factors: reasons preventing daily brushing, practical reasons, unpleasant experiences of dental care, laziness, and lack of appreciation. The reliability of the questionnaire was found to be good. Sex showed a significant correlation with reasons preventing daily brushing. Those for whom a long time had elapsed since the last visit to a dentist had more barriers relating to daily brushing, unpleasant experiences and laziness. The more educated the participants were, the fewer barriers they had in relation to the factors appreciation, unpleasant experiences, and daily brushing.

Adult↗
PubMed1992

Reasons for and incidence of tooth mortality in a Swedish population.

Longitudinal studies on tooth mortality are rare but the reasons for tooth mortality have been studied by several authors. The aims of this investigation were to study the reasons for and incidence of tooth mortality in an earlier described Swedish population of 200 patients on two occasions with an interval of 5-7 years, and to see if the reasons for extractions were correlated to posts, crowns or endodontic status, respectively. 197 (4.0%) of the 4889 teeth registered at the first examination were lost during the interval. 65 (33%) of the lost teeth were endodontically treated. 44 (68%) of these were registered as having one or more root with a root-filling ending more than 2 mm from the apex and 29 (45%) were judged to have an improper seal. In 93 of the 197 lost teeth it was possible to find the reason for extraction from the patient chart. Based on distribution of selected variables, these 93 teeth seemed to be representative of the whole group of 197. It was concluded that tooth losses were evenly distributed in the different age-groups and that above all molars but also premolars were lost more often than teeth in the frontal region. Furthermore, endodontically treated teeth were lost more often than other teeth and the quality of the root-filling affected the risk for losses while crowned teeth did not run a higher risk of being lost than teeth without crowns. Finally, it was found that caries, including pulpitis and apical periodontitis, was the main reason for tooth extractions.

Adult↗