Special article
Reflections in the clinical practice
Reflexión en la práctica clínica
Read
254
Timeswas read the article
4
Total PDF
250
Total HTML
Share statistics
array:23 [ "pii" => "S2254887414000149" "issn" => "22548874" "doi" => "10.1016/j.rceng.2013.10.005" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "857" "copyright" => "Elsevier España, S.L.. All rights reserved" "copyrightAnyo" => "2013" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2014;214:94-100" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 249 "HTML" => 249 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256513003639" "issn" => "00142565" "doi" => "10.1016/j.rce.2013.10.014" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "857" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2014;214:94-100" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1127 "formatos" => array:2 [ "HTML" => 804 "PDF" => 323 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Reflexión en la práctica clínica" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "100" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Reflections in the clinical practice" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2178 "Ancho" => 3254 "Tamanyo" => 336788 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Reflexión rápida (reconocimiento inmediato) y lenta (tenemos que buscar otros datos para proceder a emitir un diagnóstico).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Borrell-Carrió, J.C. Hernández-Clemente" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Borrell-Carrió" ] 1 => array:2 [ "nombre" => "J.C." "apellidos" => "Hernández-Clemente" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887414000149" "doi" => "10.1016/j.rceng.2013.10.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000149?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256513003639?idApp=WRCEE" "url" => "/00142565/0000021400000002/v2_201404030127/S0014256513003639/v2_201404030127/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S2254887414000125" "issn" => "22548874" "doi" => "10.1016/j.rceng.2013.08.001" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "834" "copyright" => "Elsevier España, S.L." "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Rev Clin Esp. 2014;214:87-93" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 310 "formatos" => array:2 [ "HTML" => 309 "PDF" => 1 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical up-date</span>" "titulo" => "Anal carcinoma and HIV infection: Is it time for screening?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "93" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma anal e infección por el virus de la inmunodeficiencia humana: ¿es la hora del cribado?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1182 "Ancho" => 1662 "Tamanyo" => 151000 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Action algorithm for anal carcinoma screening.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p> <p id="spar1025" class="elsevierStyleSimplePara elsevierViewall">Font: Palefsky et al<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Herranz-Pinto, E. Sendagorta-Cudós, J.I. Bernardino-de la Serna, J.M. Peña-Sánchez de Rivera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Herranz-Pinto" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Sendagorta-Cudós" ] 2 => array:2 [ "nombre" => "J.I." "apellidos" => "Bernardino-de la Serna" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Peña-Sánchez de Rivera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256513002841" "doi" => "10.1016/j.rce.2013.08.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256513002841?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000125?idApp=WRCEE" "url" => "/22548874/0000021400000002/v1_201403141104/S2254887414000125/v1_201403141104/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Reflections in the clinical practice" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "100" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Borrell-Carrió, J.C. Hernández-Clemente" "autores" => array:2 [ 0 => array:3 [ "nombre" => "F." "apellidos" => "Borrell-Carrió" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "J.C." "apellidos" => "Hernández-Clemente" "email" => array:1 [ 0 => "jcarloshc18@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departament de Ciències Clíniques, Facultad de Medicina, Universitat de Barcelona, EAP Gavarra, Institut Català de la Salut, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Psiquiatría, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reflexión en la práctica clínica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2177 "Ancho" => 3255 "Tamanyo" => 324743 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rapid (immediate recognition) and slow (we have to find other data before proceeding to a diagnosis) reflection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical practice achieves its maximum value when decisions are made in a thoughtful manner. According to the Royal Spanish Academy's dictionary, “to reflect” is to consider something carefully, in other words, to examine nonobvious possibilities for the problems patients present for us. Reflection enables us to consider the consequences of acting or doing nothing<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>; however, reflection at times provides neither efficiency or value.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Intuition has been defended as a type of rapid reasoning resulting from a long process of personal and group learning.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Experts are experts partly because they learned to recognize common errors (years of professional exercise certainly increase our assertiveness but not always our sensitivity for rectifying errors; we can make mistakes with plenty of assertiveness). They are also experts due to their ability to recognize highly complex scenarios and levels that require the appropriate use of one or another system of reasoning (slow vs. fast).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The aim of this special article is to examine a number of expert decision models and their consequences for clinical practice.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">How experts reason</span><p id="par0010" class="elsevierStylePara elsevierViewall">In the 1980s, Sackett et al. identified 3 strategies<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>: “direct recognition diagnoses” (for example, recognizing herpes zoster), a reasoning he named “hypothetical-deductive” (e.g., diagnosing headache) and another slower type he called “algorithmic” (e.g., diagnosing hyponatremia). Some years later, Schön<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> detected that experts have expertise that is preferentially activated when immersed in solving the problem. He called this tacit knowledge, a type that cannot always be recognized or recalled in other contexts (e.g., outside the office or in the operating room). In contrast, learners can have theoretical knowledge that they are not capable of using in front of the patient. One of the tasks of learning is reducing the gap between knowing something and implementing it.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Kahneman<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>, Kassirer et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Croskerry<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> all emphasize the presence of fast and slow channels for decision making (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Experts should recognize the complexity of a clinical situation in which they should act by applying slow reasoning.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">From the standpoint of improving decision making, the teams led by Crandall and Klein<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,9</span></a> studied (in the early 2000s) various professional environments (engineers, meteorologists, physicians and nurses) and reached the conclusion that expertise has at least the following characteristics:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0020" class="elsevierStylePara elsevierViewall">The expert internalizes a model that explains how things work (within their field of expertise). These models can be both prescriptive (what has to be done) and predictive (what will happen given certain circumstances).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0025" class="elsevierStylePara elsevierViewall">Experts also have certain highly developed perceptive skills in their field and are able to verbalize their observations (e.g., the descriptions reported by a radiologist).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0030" class="elsevierStylePara elsevierViewall">Experts define very well what is or is not “typical”, i.e., the variability of the phenomenon and when this phenomenon should be categorized in another manner. In medicine, this line of thought has led to the development of the theory of illness scripts.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall">Experts have well-established routines that are stable over time and that they learn to supervise and enrich. In the medical field, we talk not only about exploratory maneuvers, the preparation of case histories and methods of communicating with patient, but also of the routines and inertia of reasoning.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall">Declarative knowledge: “faced with this condition, we must do the following” or “we must change the diagnosis if the patient does not respond to this drug”. We are in the field of criteria, which can be defined as standards that connect a fact of reality with a judgment or a recommended action.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Experts know how to apply them and put them into words.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">We can see that the reflexive act has 2 ingredients: defining the situation and choosing a behavior. The first of these steps in the clinical setting consists of admitting that the patient's problem is our responsibility, (i.e., that the patient has a health problem <span class="elsevierStyleItalic">that we will be responsible for even if we do not know how to accurately define it or describe it</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>). The second step is to search our memory for similar situations (experiences) <span class="elsevierStyleItalic">in order to label it.</span> Once this process, which barely lasts a few minutes, is frustrated (that is, when we are unable to immediately recognize the nature of the problem), we are forced to “slice up” the problem and consider those semiological clues that suggest or impel a specific diagnostic or therapeutic conduct. On such occasions, we do not know what the patient has, <span class="elsevierStyleItalic">but we do know what has to be done (delay the resolution of the clinical act to allow us time to reason slowly, consult with colleagues, apply algorithms, conduct a follow-up</span>, etc.).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Emotional issues in decision-making</span><p id="par0050" class="elsevierStylePara elsevierViewall">The contributions of Crandall and Klein do not list, however, the emotional elements with which expert knowledge needs to be equipped. Let us imagine a typical on-duty day; the physician has to solve <span class="elsevierStyleItalic">routine</span> cases through habits (acquired through great effort) relating to <span class="elsevierStyleItalic">exploration</span>, communication and reasoning. Up to this point, the Crandall and Klein model works perfectly. However, the greater challenge that faces the clinician is perceiving what falls outside the routine, for example, a case that <span class="elsevierStyleItalic">appears to be a banal disease but is not.</span> The decision that has to be made is: Should I stop with this patient and request more examinations, or can I discharge the patient with conservative measures? If we translate it to the model in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>: Can I continue with a quick decision, or should I take the slow road? This would be the case for a patient with multiple diseases who is admitted for abdominal discomfort and in whom all the examinations are normal except for positive right abdominal decompression.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This decision is not merely cognitive; it has, in fact, an emotional component of considerable importance. In healthcare systems (private and public) that were, are or will be based on rationing, the physician is under constant <span class="elsevierStyleItalic">resolution pressure</span>, i.e., the physician is under environmental pressure to resolve the clinical case without delay. There is evidence that haste and <span class="elsevierStyleItalic">overconfidence</span> result in the premature closure of clinical interviews with regrettable consequences.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–16</span></a> Another method of closing the clinical interview prematurely is to dismiss or belittle the patient's requests. Many of Croskerry's so-called cognitive traps<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> lie in this direction, for example:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0060" class="elsevierStylePara elsevierViewall">Doctor, I see lights when I move my eyes, especially in the dark.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Don’t worry; that happens to lots of people.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">These cognitive traps act as justification for finishing the clinical interview and saving us the painful “slow reflection” or the costs of a worse hypothesis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The perception of cost (waking a colleague, delaying the discharge) is usually more <span class="elsevierStyleItalic">emotional</span> than <span class="elsevierStyleItalic">cognitive</span><span class="elsevierStyleBold">.</span> The clinician <span class="elsevierStyleItalic">feels</span> that if they take this path then <span class="elsevierStyleItalic">everything becomes more complicated.</span> At 3 in the morning, a physician can reason as follows: “<span class="elsevierStyleItalic">This patient has positive abdominal decompression but limited to the right abdomen. The rectal examination shows a Douglas pouch without pain; therefore, the patient does not have appendicitis. I am not going to bother a nurse to obtain a blood sample. Much less am I going to bother the radiologist. Therefore, I will discharge the patient, and if they continue to feel discomfort I will tell them to return.”</span></p><p id="par0080" class="elsevierStylePara elsevierViewall">However, if this patient returns with septic shock, the clinician will feel a moral regret that will influence future decisions. While the learner prioritizes relieving the pressure of a full waiting room, the expert remembers the moral regret from the premature closure of a case, and their priority is no longer “resolving cases at all costs”, but rather neutralizing risks as much as possible.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, not all clinicians perceive (or admit) that they have erred or learn in a similar manner. Denying or minimizing an error is a strategy that approximately 20% of physicians chose (this percentage can decrease to the extent that the organizations in which they work have a culture of clinical safety).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The majority, however, accept that they have erred and will record some of the information about the situation as future warning signs: “<span class="elsevierStyleItalic">Be careful! All clearly positive decompression deserves a detailed assessment</span>”. Some clinicians, albeit few, will ask themselves how they felt or what emotional factors influenced their reasoning: fatigue, physical discomfort, laziness, fear, enthusiasm, etc. <span class="elsevierStyleItalic">We can therefore talk about at least</span> 3 styles of learning:</p><p id="par0090" class="elsevierStylePara elsevierViewall">The denial style: “The patient had a retrocolic plastron that fooled the diagnosis greatly. I do not have to feel responsible for any error; even the best doctor would have missed it.”</p><p id="par0095" class="elsevierStylePara elsevierViewall">The criteria-based style: “When dealing with patients with clearly positive decompression, I should take precautions and, as a minimum, request laboratory and ultrasound tests, regardless of what shift it is.”</p><p id="par0100" class="elsevierStylePara elsevierViewall">The emotional maturity style: “I have not paid sufficient attention to this voice telling me that the decompression was abnormal and have not done so because I am impetuous and classify cases as banal or severe without other matrices, which leads me to discharging patients who deserve more study.”</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Dynamics of reflection</span><p id="par0105" class="elsevierStylePara elsevierViewall">It would be foolish to think of the quick path of <span class="elsevierStyleItalic">reasoning</span> as a mere exercise in reflex or conditioned behaviors. For example, (the physician's thoughts are in italics):</p><p id="par0110" class="elsevierStylePara elsevierViewall">“Doctor, I’m here because I have a cough (the patient entered with a smile and wants me to relieve the cough). It's a dry cough (I’m seeing numerous cases of viral tracheitis these days) that doesn’t bring anything up. My throat itches like crazy (Careful! This could be drug-related), especially at night, (that points to ACEI-induced cough) and with some fever (Ah! That once again points to an infection).</p><p id="par0115" class="elsevierStylePara elsevierViewall">The speed of this reflection belies its significant complexity. The initial <span class="elsevierStyleItalic">observation</span> of the physician (“<span class="elsevierStyleItalic">the patient entered with a smile and wants me to relieve the cough</span>”) is qualitatively different from the following <span class="elsevierStyleItalic">(irritating cough, drug-related</span>, etc.). The physician determines in seconds that he or she is dealing with a noncombative patient (we start with a good healthcare relationship, <span class="elsevierStyleItalic">or so the patient's attitude and our experience leads us to believe</span>) and that the patient is asking us to define their health problem. An aggressive patient will trigger alarms and will probably result in a different type of interview. In this spirit of a “normal relationship”, the setting and context of the clinical interview delimits what we have called the interview modality, which could be synthesized as, “what does the patient want of me?” In the case where we try to think, “<span class="elsevierStyleItalic">The patient comes here so that I can relieve his cough and then I tell him that this is a significant problem</span>”, i.e., it results the modality of a semiological interview.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Once the physician has decided that the interview lies within a semiological framework, he or she puts forth the initial hypotheses and attempts to verify them. This examination (verbal and physical) provides new “raw” information that confirms or disproves these initial hypotheses, until a <span class="elsevierStyleItalic">synthesis or summary</span> has been made, which tends to have the form, “<span class="elsevierStyleItalic">I have a patient with a 3-day-old cough, with little sputum, fever, no history of COPD or smoking, and with rhonchi and wheezing. This could be an acute bronchitis. Yes, I’m almost sure of it.”</span></p><p id="par0125" class="elsevierStylePara elsevierViewall">Everything is ready for the physician to proceed to the resolution of the interview, offering the patient the following: <span class="elsevierStyleItalic">You have bronchitis. I recommend you use this inhaler</span>, etc. However, the presence of crackles (instead of rhonchi) would have been enough to change the illness script. Among other possibilities, a pneumonic process or bronchiectasis could then have been considered. The “<span class="elsevierStyleItalic">almost sure” qualifier</span> would disappear or change. Let us dwell for a moment on the fact that this “<span class="elsevierStyleItalic">almost sure”</span> qualifier is known as the modal <span class="elsevierStyleItalic">qualifier</span>,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> a <span class="elsevierStyleItalic">qualifier</span> that can go from “<span class="elsevierStyleItalic">I do not know what the patient has”</span> to “<span class="elsevierStyleItalic">I am sure I know what the patient has.”</span> A prudent and reliable habit in the use of these <span class="elsevierStyleItalic">qualifiers</span> leads us to higher quality reflection. Can we control the verbal expressions of probability? Undoubtedly, and in the same way we try to talk in an educated and courteous manner. Controlling the way we express ourselves leads us to consider the skills of the so-called metacognitive thoughts.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Importance of metacognition and the quality of reflection</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are two planes of reflection that overlap in the clinical interview. So far we have described tasks involving case histories and physical examinations, which we regularly perform. However, in a different plane we think, “<span class="elsevierStyleItalic">How am I doing on time? Am I performing all the tasks that are required for this consultation?”</span> There is agreement in naming this second plane <span class="elsevierStyleItalic">metacognitive reflection</span>, i.e., thinking about our thought process or on the procedures that we perform. Smith et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> label the following types of questions <span class="elsevierStyleItalic">metacognition-self</span> (metacognition of the “I”): What is asked of me? Am I performing the tasks that should be performed? <span class="elsevierStyleItalic">Do I reflect with expressions of probability (and not of certainty)?</span> The authors label <span class="elsevierStyleItalic">metacognition-other</span> (metacognition of the other) questions such as, “<span class="elsevierStyleItalic">Is this what the patient wants (or expects)? How will the patient react if I tell him that there is a 40% probability of the biopsy being positive? Or if I tell him that he has to take this…?”</span> We have to add to this model the <span class="elsevierStyleItalic">metacognition-illness</span> (metacognition of the disease), which is none other than reflecting on the illness script. For example, “<span class="elsevierStyleItalic">Am I considering all diagnostic options? Have I paid attention to all the details of the patient's evolution to confirm that this is expected for the disease?”</span></p><p id="par0135" class="elsevierStylePara elsevierViewall">There is widespread agreement that <span class="elsevierStyleItalic">there is no expertise without metacognition</span>. Metacognition is an important aspect of the quality of reflection, although not the only one.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Other variables, in addition the metacognitive, substantially influence the quality of reflection (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>). It is not easy to define the term <span class="elsevierStyleItalic">quality</span> when talking about <span class="elsevierStyleItalic">reflection</span>, but we would all agree in that the final result of the clinical act depends in part on this quality. A reflection that is pertinent (directed toward the necessary objective for the patient's health), comprehensive (analyzes the various facets of the problem), consistent (seeks an explanation by applying noncontradictory scientific models approved by the scientific community), reliable (has the same results if the analysis is repeated), prudent (assigns weight and probabilities) and frugal (seeks the simplest explanation) would be a quality reflection..</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">With our reflection, we construct narratives full of sense, but we construct these narratives because we have illness scripts <span class="elsevierStyleItalic">that serve as a framework. However, we need to highlight two dangers:</span> We apply a “verisimilitude filter” <span class="elsevierStyleItalic">on the narratives</span> consisting of the automatic ruling out of data that do not fit with the diagnosis that we are backing. <span class="elsevierStyleItalic">Therefore, we sometimes do not record a finding from the exploration.</span></p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">On the other hand, the phenomenon of group conformity</span> consists of accepting the general opinion that one has of a patient. An example of this is a patient labeled as hypochondriac who shows symptoms of rhizomelic weakness without us paying the patient renewed attention. Cultivating independence of criteria is to constantly ask “<span class="elsevierStyleItalic">What do I think of these clinical symptoms, even though it does not agree with the opinion of my colleagues?”</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Supervision of tasks</span><p id="par0155" class="elsevierStylePara elsevierViewall">It has been proposed that metacognition be activated by creating the habit of supervising our own tasks. This habit consists of asking ourselves if we have completed some of the key interview tasks and, more generally, whether we are working in a comfortable manner (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). This is how it would work:</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The practitioner greets the patient and asks about the reason for the visit. The physician performs a complete review of the patient's case history and a physical examination. However, before completing them, the doctor asks himself, “<span class="elsevierStyleItalic">Can I write a complete report with the information collected so far?”</span> Before ending the interview, he asks himself again, “<span class="elsevierStyleItalic">Have I have considered the worse hypothesis possible</span>?” The doctor proposes a treatment to the patient but before filling out the prescription, the doctor asks himself, “<span class="elsevierStyleItalic">Is the selected treatment safe for this patient profile?”</span></p><p id="par0165" class="elsevierStylePara elsevierViewall">This is a habit that is easier to understand at the intellectual level than to apply systematically. It becomes a check-list of the quality of the clinical act, and as a check-list, it raises the level of demands and fatigue. However, the smart clinician learns that the bother of incorporating it into their standard process is rewarded by the avoidance of clinical errors and the moral regret they would entail. This is about finishing the consultation with the feeling that “<span class="elsevierStyleItalic">I did all that should have been done.”</span></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Practical consequences. <span class="elsevierStyleItalic">Rectification</span> scenarios</span><p id="par0170" class="elsevierStylePara elsevierViewall">We can conclude that there is a growing interest in studying the reflection performed by practitioners in the context of the clinical act. If we were able to increase its quality (the quality of reflection), we would avoid clinical errors and improve efficiency. We have studied the dynamics of reflection (framework - modality of the interview – tasks -summary prior to the resolution of the interview), paying attention to the skills of metacognition and proposing a general strategy that we call “supervision of tasks.” A teaching implementation of this strategy would be based on two pillars:</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Integrate the habits of supervision</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Propose</span> clinical scenarios that, in order to be properly solved, the learner must rectify the first hypothesis that occurs to them. We call these scenarios “<span class="elsevierStyleItalic">rectification</span> scenarios”, because they require us to reprocess the framework or the illness script that we have initially chosen.</p><p id="par0180" class="elsevierStylePara elsevierViewall">There are two types of <span class="elsevierStyleItalic">rectification</span> scenarios: clinical symptoms that appear to be one entity and are in fact another. We call this type “<span class="elsevierStyleItalic">illness script” rectification.</span> The other <span class="elsevierStyleItalic">rectification</span> refers to the intent or overall framework of the interview; for example, the patient has a hidden demand, an added demand or a confusing demand. In any case, when we discover it, we are obliged to make a radical change in strategy. This <span class="elsevierStyleItalic">occurs</span> numerous times just when we think the interview is almost over! This <span class="elsevierStyleItalic">rectification of the overall framework of the interview</span> represents a notable effort on the part of the interviewer.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The benefit of these types of clinical scenarios is to accustom the clinician to rectifying without moral regret, to not getting anchored to a single diagnostic option (much less risk his prestige) and to reprocess the needs of his patient's health without prejudice, while being highly alert to new evidence that might arise. As Michel Montaigne states, “...<span class="elsevierStyleItalic">loving to gratify and nourish the liberty of admonition by my facility of submitting to it, and this even at my own expense.</span>” This is a program for the physician of the 21th century.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres321899" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec304259" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres321900" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec304260" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "How experts reason" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Emotional issues in decision-making" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Dynamics of reflection" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Importance of metacognition and the quality of reflection" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Supervision of tasks" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Practical consequences. Rectification scenarios" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Integrate the habits of supervision" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-01" "fechaAceptado" => "2013-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec304259" "palabras" => array:4 [ 0 => "Decision making" 1 => "Clinical decision-making" 2 => "Patient safety" 3 => "Professional practice" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec304260" "palabras" => array:4 [ 0 => "Toma de decisiones" 1 => "Toma de decisiones clínicas" 2 => "Seguridad del paciente" 3 => "Práctica profesional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purpose of this article is to analyze some models of expert decision and their impact on the clinical practice. We have analyzed decision-making considering the cognitive aspects (explanatory models, perceptual skills, analysis of the variability of a phenomenon, creating habits and inertia of reasoning and declarative models based on criteria). We have added the importance of emotions in decision making within highly complex situations, such as those occurring within the clinical practice. The quality of the reflective act depends, among other factors, on the ability of metacognition (thinking about what we think). Finally, we propose an educational strategy based on having a task supervisor and rectification scenarios to improve the quality of medical decision making.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El propósito de este artículo especial es el análisis de algunos modelos de decisión experta y sus consecuencias en la práctica clínica. Analizamos la toma de decisiones desde aspectos cognitivos (modelos explicativos, habilidades perceptivas, análisis de la variabilidad de un fenómeno, creación de hábitos de razonamiento y modelos declarativos basados en criterios), y añadimos la importancia de las emociones en la toma de decisiones en situaciones de alta complejidad como las que tienen lugar en la práctica clínica. La calidad del acto reflexivo depende, entre otros factores, de la capacidad de metacognición (pensar en lo que pensamos). Finalmente, proponemos una estrategia docente basada en cultivar un supervisor de tareas y en la creación de escenarios de rectificación como medio de elevar la calidad en la toma de decisiones médicas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Borrell-Carrió F, Hernández-Clemente JC. Reflexión en la práctica clínica. Rev Clin Esp. 2014;214:94–100.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2177 "Ancho" => 3255 "Tamanyo" => 324743 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rapid (immediate recognition) and slow (we have to find other data before proceeding to a diagnosis) reflection.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Quality of reflection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables that increase it \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables that decrease it \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Richness in the production of occurrences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple semantic and perceptive associations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Associative poverty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Manner of processing occurrences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Alert and “taking notes” on the occurrences– Understand the conditions that limit the occurrences– Deactivate, in part, the filter of verisimilitude (admitting the inconsistent, cultivating the perplexity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Group thinking aimed at conformity– Working in a group culture characterized by obedience– Authoritarian or paternalistic leadership that penalizes discrepancies– Type of orientation of highly focal, detail-oriented care but unaccustomed to examining the phenomena to all its extents and all future implications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Routines or habits of metacognition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Practitioners who systematically perform task supervision– Practitioners who not only supervise the tasks they perform but also how they feel performing them \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Practitioners having significant difficulty developing task performance supervision or reasoning supervision \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab468356.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Quality of reflection. Variables.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Trait \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Possible consequences \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Determinants of attitude \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cold, distant and “highly technical” practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">By dismissing the issues of doctor-patient relationship and patient suffering, the doctor can consider that the patient “complains too much” or is faking the symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Practitioner hypersensitive to the suffering of others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">An excess of sympathy (which is not empathy) can lead to exaggerating the importance of certain patient symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Practitioner who seeks to “please” in excess \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The practitioner will justify unreasonable demands (for example, for additional examinations that are not indicated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Determinants of character \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Highly attributive practitioner (everything has to have a cause) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Might blame the patients or force baseless causal explanations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stubborn practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Once a diagnosis is made, it becomes very hard for the doctor to rectify it, and they can even distort reality to show they are right \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fearful, overly cautious and defensive practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">This combination of traits leads practitioners to reassuring behavior: frequent follow-up visits, additional unnecessary tests, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Authoritative practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If the patient suggests a diagnosis, the practitioner immediately attempts to dismiss it \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paternalistic practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wishes to protect the patient, which sometimes leads the doctor to make inappropriate assurances, and ultimately, believe their own statements (“you’ll see how your cancer is healed”). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimistic-denier practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wishes to impart a feeling of optimism to the healthcare relationship but at the cost of denying or dismissing objective information that indicate health problems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Egodystonic practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transfers their own psychological discomfort to the patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Solipsistic practitioner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lives in their world, thereby missing information that would be clearly obvious if their observational ability were sharper \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab468355.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Quality of reflection. Determinants of attitude and character.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Start, before starting the interview</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Am I sufficiently “present” and clear headed? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Do I have a sufficiently positive attitude toward the patient? Do I smile at the patient? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Do I have an overall picture of this patient? Should I have one before continuing? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Exploratory phase</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Am I clear on the reason for which the patient is visiting? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Is something interfering with my ability to concentrate and perform the tasks of anamnesis and physical examination? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Am I in a hurry to close the exploratory phase of the interview? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Clinical decision</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Can I make a decision now and resolve the interview, or do I lack information? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Can I write a report with a detailed chronology of the symptoms? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Reading: If instead of “listening” to the patient's symptoms I read them from a book, what would come to mind? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Reverse hypothesis: If these biological symptoms are not the result of this cause, are they psychosocial in origin? (and vice versa) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–What influence do my knowledge and prejudices about this patient have? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Is there a missing relevant fact or some ethical issue? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Resolution phase just before closure</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–What would a good clinician say about this interview? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Am I doing everything possible for this patient? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">–Did I leave out preventive issues? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab468357.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Task supervision in the clinical interview.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:2 [ "titulo" => "A companion to the philosophy of action" "serieFecha" => "2013" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "On reflection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. Kornblith" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "University Press" "editorialLocalizacion" => "Oxford" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thinking fast and slow" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Kahneman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2011" "editorial" => "Penguin" "editorialLocalizacion" => "London" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical epidemiology: a basic science for clinical medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.L. Sackett" 1 => "R.B. Haynes" 2 => "P. Tugwell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1985" "editorial" => "Little, Brown" "editorialLocalizacion" => "Boston" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The reflective practitioner: How professionals think in action" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.A. Schön" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1983" "editorial" => "Basic Books" "editorialLocalizacion" => "New York" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Working minds: a practitioner's guide to cognitive task analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Crandall" 1 => "G. Klein" 2 => "R.R. Hoffman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2006" "editorial" => "The MIT Press" "editorialLocalizacion" => "Cambridge" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manual de razonamiento clínico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.P. Kassirer" 1 => "J.B. Wong" 2 => "R.I. Kopelman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2011" "editorial" => "Wolters Kluwer/Lippincott Williams & Wilkins" "editorialLocalizacion" => "Barcelona" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A universal model of diagnostic reasoning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Croskerry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACM.0b013e3181ace703" "Revista" => array:6 [ "tituloSerie" => "Acad. Med." "fecha" => "2009" "volumen" => "84" "paginaInicial" => "1022" "paginaFinal" => "1028" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19638766" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Streetlights and Shadows. Searching for the keys to adaptative decision making a Bradford book" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2009" "editorial" => "The MIT Press" "editorialLocalizacion" => "Cambridge" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How expertise develops in medicine: knowledge encapsulation and illness script formation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.G. Schmidt" 1 => "R.M. Rikers" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2923.2007.02915.x" "Revista" => array:6 [ "tituloSerie" => "Med. Educ." "fecha" => "2007" "volumen" => "41" "paginaInicial" => "1133" "paginaFinal" => "1139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18004989" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simple heuristics that make us smart" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "the ABC Research Group" "etal" => false "autores" => array:2 [ 0 => "G. Gigerenzer" 1 => "P.M. Todd" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1999" "editorial" => "Oxford University Press" "editorialLocalizacion" => "New York" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Minimizing diagnostic error: the importance of follow-up and feedback" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.D. Schiff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2008.09.012" "Revista" => array:7 [ "tituloSerie" => "Am. J. Med." "fecha" => "2008" "volumen" => "121" "numero" => "Suppl 5" "paginaInicial" => "S38" "paginaFinal" => "S42" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18954591" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overconfidence as a cause of diagnostic error in medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.S. Berner" 1 => "M.L. Graber" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2008.05.016" "Revista" => array:7 [ "tituloSerie" => "Am. J. Med." "fecha" => "2008" "volumen" => "121" "numero" => "Suppl 5" "paginaInicial" => "S2" "paginaFinal" => "S23" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18638615" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The importance of cognitive errors in diagnosis and strategies to minimize them" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Croskerry" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acad. Med." "fecha" => "2003" "volumen" => "78" "paginaInicial" => "775" "paginaFinal" => "780" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12915363" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preventing clinical errors. A call for self-awareness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Borrell" 1 => "R.M. Epstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Fam Med" "fecha" => "2004" "volumen" => "2" "paginaInicial" => "310" "paginaFinal" => "316" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15335129" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seguridad clínica en atención primaria. Los errores médicos (II)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Borrell Carrió" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.aprim.2011.07.013" "Revista" => array:6 [ "tituloSerie" => "Aten. Primaria" "fecha" => "2012" "volumen" => "44" "paginaInicial" => "494" "paginaFinal" => "502" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22055915" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seguridad clínica en atención primaria. El enfoque sistémico (I)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Borrell Carrió" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.aprim.2011.07.014" "Revista" => array:6 [ "tituloSerie" => "Aten. Primaria" "fecha" => "2012" "volumen" => "44" "paginaInicial" => "417" "paginaFinal" => "424" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22030262" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El modelo argumentativo de Toulmin en la escritura de artículos de investigación educativa [en línea]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.I. Rodríguez Bello" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Revista Digital Universitaria" "fecha" => "2014" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psychological investigations of competence in decision making" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Smith" 1 => "J. Shanteau" 2 => "P. Johnson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2004" "editorial" => "Cambridge University Press" "editorialLocalizacion" => "Cambridge" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Demanda y queja en la entrevista clínica, conceptos clave para una práctica clínica segura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Borrell i Carrió" 1 => "J.C. Hernández-Clemente" 2 => "J. Lázaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medcli.2009.06.032" "Revista" => array:6 [ "tituloSerie" => "Med. Clin. (Barc)." "fecha" => "2011" "volumen" => "136" "paginaInicial" => "390" "paginaFinal" => "397" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19732917" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021400000002/v1_201403141104/S2254887414000149/v1_201403141104/en/main.assets" "Apartado" => array:4 [ "identificador" => "3982" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021400000002/v1_201403141104/S2254887414000149/v1_201403141104/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414000149?idApp=WRCEE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 1 | 4 | 5 |
| 2018 February | 6 | 0 | 6 |
| 2018 January | 5 | 0 | 5 |
| 2017 December | 10 | 0 | 10 |
| 2017 November | 12 | 0 | 12 |
| 2017 October | 8 | 0 | 8 |
| 2017 September | 15 | 0 | 15 |
| 2017 August | 10 | 0 | 10 |
| 2017 July | 12 | 0 | 12 |
| 2017 June | 11 | 0 | 11 |
| 2017 May | 14 | 0 | 14 |
| 2017 April | 10 | 0 | 10 |
| 2017 March | 9 | 0 | 9 |
| 2017 February | 9 | 0 | 9 |
| 2017 January | 15 | 0 | 15 |
| 2016 December | 14 | 0 | 14 |
| 2016 November | 20 | 0 | 20 |
| 2016 October | 24 | 0 | 24 |
| 2016 September | 19 | 0 | 19 |
| 2016 August | 15 | 0 | 15 |
| 2016 July | 11 | 0 | 11 |
Show all
