Personal Experience Of A Physician (TREDITION CLASSICS)

Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one.

Personal Experience of a Physician (TREDITION CLASSICS)

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The objective of this study is to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one. In so doing, this study aims to better understand the intricacies of individual physician unlearning in order to inform more successful de-implementation strategies for outmoded, ineffective clinical practices.

Our study participants consisted of a purposeful and carefully selected group of primary care generalist physicians who practice at a single urban academic tertiary care facility, the Cleveland VA Medical Center and its community-based outpatient clinics. This provided a relatively homogeneous group, as these physicians have similar training backgrounds, clinical experiences, and institutional influences. After interviewing an initial group of five physicians suggested by one of the authors (DCA), we asked each respondent if they could recommend other physicians who would be interested in and qualified to be interviewed for this project. Using this snowball sampling, we continued to interview physicians until we reached the point of theme saturation, which was achieved with a sample size of 15 respondents.

The interviews were conducted using an interview guide with open-ended questions designed to elicit detailed and thoughtful answers. The interview guide is shown in the Additional file 1. We encouraged participants to speak openly regarding their personal experiences with specific examples of practice change and to reflect upon how they responded to such change. Their examples are shown in Table 1. We followed up each question with probing questions to help guide or re-direct the conversation when necessary. We ended each interview, asking participants for their comments regarding practice in general. This method was successful in engaging the participants and in prompting their discussion of factors that they might not have otherwise spontaneously volunteered. Each interview lasted between 20 and 30 min, consistent with the time period of which participants were informed.

While guidelines do help to guide practice, they do not instruct on how to implement a practice change in every patient scenario. As a result, successful unlearning requires physicians to not only use their prior experience and clinical judgment but also build new experience with the practice change in a continual fashion to engage in the new equilibrium.

There is a disparity between the biomedical categorization of human disruptions as disease and the patient's personal and social experience of illness. The dichotomy between disease and the illness experience has provoked extensive commentary. It has been proposed that the inability to deal with illness is a major failing of biomedicine. Cross-cultural circumstances often magnify the discrepancy between the views held by patients and health care providers. The inability to recognize and deal with perspectives of illness that deviate from those of the biomedically trained practitioner can paralyze attempts at identifying problems and developing plans for solving them.

Patients may connect life process and symptomatology in a way that does not fit with biologic definitions.2 In addition, special knowledge and popular health beliefs may play a prominent role in patient concerns. Individual experience with traditional practices and beliefs as well as the ability to articulate them may vary. Many cultures discourage the revelation and exposure of personal and family issues. Unfortunately, biomedical focus often precludes these revelations, and they remain unrevealed and unspoken.

Since the expectations set by traditions vary, the question arises: how does a non-Western traditional patient react to biomedical diagnostic techniques and settings? As the personal experiences and background of provider and patient are increasingly disparate, each participant has diminished ability to relate to the other's perception of the illness experience. As a result, it is useful for the provider to shift the interview focus as follows.

It is useful to discuss the whereabouts and current activities of family members. Look for similar symptoms or illness in the family, and establish the dates and possible causes of these events. For example, in Native American and refugee families it is quite common to discover multiple incidents of loss, injury, and illness. Look for problems and events within family and community that the patient ties to the illness experience. Explore life events, day-to-day activities, and interpersonal relationships. Irrespective of the character and source of the current illness episode, narratives regarding prior life experiences help uncover the focus of patient views and explanations.

At times, however, direct inquiry is unsatisfactory. Many groups and individuals will not discuss personal or ethnocentric views until the interview technique is altered. Furthermore, some individuals feel that the direct questions about what they think has caused their problem are a sign that the provider is uncertain ("If you don"t know what's caused my problem, I"m in the wrong place."). This issue was pointed out by Harwood (1981), who noted that some ethnic groups "expect the physician to be the ultimate experts on diagnosis and treatment."

Individuals often have personal vocabularies that do not include the terminology used by health care providers. Personal vocabularies can vary based on language skills, ethnicity, intelligence, education, and socialization. Prior life experience may lead an individual to attach special meanings to a specific term or circumstance. "Terms such as "diabetes," "rheumatoid arthritis," or "multiple sclerosis" may seem deceptively simple. Careful analysis will disclose that they represent a complex set of physiologic, chemical and structural facts" (Fabrega, 1975). Terms that seem common to providers are often perceived and understood in a fashion that does not match the originally intended meaning.

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Locke believes that this account of personal identity as continuity of consciousness obviates the need for an account of personal identity given in terms of substances. A traditional view held that there was a metaphysical entity, the soul, which guaranteed personal identity through time; wherever there was the same soul, the same person would be there as well. Locke offers a number of thought experiments to cast doubt on this belief and show that his account is superior. For example, if a soul was wiped clean of all its previous experiences and given new ones (as might be the case if reincarnation were true), the same soul would not justify the claim that all of those who had had it were the same person. Or, we could imagine two souls who had their conscious experiences completely swapped. In this case, we would want to say that the person went with the conscious experiences and did not remain with the soul.

Heo Joon is one of the best-known physicians of the Chosun Dynasty, the last imperial dynasty (13921910) of Korea. He had served King Seonjo () during his practice, and has produced many publications on medicine. Then, how did he actually treat the patients? So far, other than the case when he treated Gwanghaegun's smallpox, it is not clearly known how and when he attended and treated the ill. In his most famous book, the Treasured Mirror of Eastern Medicine, he details the physiopathological mechanisms, diagnoses, treatments or prescriptions, and treatment cases, however, it is not clear if they're from his own clinical experiences. Nevertheless, based on the written method, the original information is reconstituted according to its respective editors of the TMEM, a particular case being included may be considered as an agreement and acceptance of an actual treatment executed. This research analyzes what type of medicinal theory that the main writer Heo Joon employed in his real treatments, as well as how he diagnosed and treated diseases. After analyzing the complete series of the TMEM, we found a total of 301 clinical cases. Here, one may wonder, why does the Section of Inner and External Bodily Elements, that deal with diseases and the structure of the body, have far outnumber cases than the Section of Miscellaneous Disorders? Why does the TMEM introduce the various types of disease experiences and treatment cases, medical cases, simple treatments, nurturing life, materia medica, and also include supernatural phenomena? Why does the TMEM include the experiences and cases from the book published in the Song, Jin, Yuan dynasty of China, moreover in the Ming Dynasty of its time. These questions can be answered to the extent that Heo Joon and the others who participated in completing t