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PubMed1976

A conceptual framework for measuring clinical problem-solving.

Most attempts to measure clinical competence start by modeling the clinician's problem-solving process. The conflicting data from studies built around this approach suggest the need for rethinking the underlying concepts. Presented is a conceptual framework for clinical competence which is a natural expansion of earlier approaches. The framework is based upon defining the domain in which the clinician functions as the starting point for measuring clinical competence. There are three dimensions to the framework-problem-solving process, clinical discipline, and context of care. The intersection of the dimensions defines the clinical practice domain to be measured. For each domain specific problems can be identified and clinicians asked to demonstrate competence in resolving them.

Clinical Competence↗
PubMed1989

Occupational therapy in early intervention: a family-centered approach.

This article describes a framework for occupational therapy service provision in early intervention settings and presents pilot data aimed at examining the framework's effectiveness. The Family-Centered Framework for Early Intervention is a synthesis of concepts from the Model of Human Occupation (Kielhofner & Burke, 1980) and from the literature on play. It encompasses a systematic, holistic approach that considers the child and the family within the context of their life environments. In this framework, play is used both as an evaluative tool and as an intervention modality that addresses the volition, habituation, and performance of the child and family as well as the strengths and weaknesses of the environment. Play is also used as a primary measure of competence and change. This framework may be useful in defining occupational therapy roles for the early intervention population.

Child, Preschool↗
PubMed1992

Dementia management: an occupational therapy home-based intervention for caregivers.

This paper describes an occupational therapy intervention designed for family caregivers of persons with dementia. The intervention, based on the framework of a competence-environmental press model and the principle of collaboration, was implemented during 5 home visits. Each visit was designed to build caregiving skills through collaboration in identifying problem areas, developing and implementing environmental strategies, and modifying management approaches. A case vignette illustrates the therapeutic process and outcomes. The theoretical rationale and structure of the intervention and innovative documentation for evaluation of the theoretic process are also presented.

Alzheimer Disease↗
PubMed1989

Pediatric dermatology in primary care medicine.

Dermatologic conditions in children pose a special dilemma to primary care physicians. On the one hand, dermatologic problems are so common in childhood that the primary care physician is forced to become involved with many of them; on the other hand, the scope of dermatologic conditions found in children is so broad as to be beyond the skills of most primary care physicians. The secret to managing dermatologic problems in children within a primary care setting is to recognize that a relatively small group of conditions encompass the vast majority of reasons for which a primary care physician will be consulted. By recognizing those conditions and becoming expert in the treatment of those well-defined areas, the primary care physician can perform a true service. Critical to this approach, however, is to establish clear limits and to practice within the framework of one's competence. Recognizing the importance of early referral of those cases that fall outside one's expertise is an important measure of the primary care physician's competence as seen by patients and their families. This article attempts to assist primary care physicians in developing their own set of guidelines.

Adolescent↗
PubMedDate not supplied

The application of competency-based education to consultation-liaison psychiatry: III. Implications.

In this paper the authors consider the implications of a competency-based model of education in relation to issues that affect the training of consultation-liaison psychiatrists. These issues include program design, the integration of consultation-liaison psychiatry to psychiatry in general, and the relationship of consultation-liaison psychiatry to medicine. Training programs in consultation-liaison psychiatry need to respond to the issues that derive from each of these areas. The authors argue that the competency-based model provides a framework which offers guidelines for designing a program that addresses these concerns.

Clinical Competence↗
PubMed1976

A general systems approach to severe family pathology.

The author proposes a general systems approach to the examination and understanding of family functioning. Scrutinizing the family as an open system with 1) evolutionary goals and tangible tasks, 2) a need for "semipermeable" boundaries, 3) cultural and subcultural communication modes, 4) leadership effectiveness, and 5) the nature and age-appropriateness of the affective bonds will enable clinical judgements about family functioning that indicate general system competencies and defects. Such a framework may also lead to a typology of family process because the major functions of the family as a system (creation, nurturance, enculturation, and guidance of the young into adulthood) can be evaluated regardless of symptoms or diagnoses.

Communication↗
PubMed1990

The politics of universal access: the Massachusetts Health Security Act of 1988.

This article analyzes the passage of an unprecedented state law, promising every resident access to affordable health insurance. The Massachusetts Health Security Act of 1988 was the product of a set of political and financial pressures that had been developing for nearly a decade. Hospital, insurance, and business interests were unable to reach a new accommodation on hospital payment. This logjam created the opportunity for a policy breakthrough, but did not inherently lend itself to progressive reform. It was consumer activism that forced the traditional powers in health policy to address the interests of the uninsured. By imposing a more public-interest agenda on the process, consumers were able to change the configuration of the stalemate, but could not resolve it. The particular terms of the stalemate, however, made possible a new, more aggressive role for state government in health policy. Unable to satisfy their competing interests within a policy framework that had universal access as a goal, traditionally powerful interest groups found themselves increasingly dependent on the state to broker a new agreement. While the many concessions made to these groups are likely to prove to be the bill's undoing, the unraveling of the agreement will not end the story. The same pressures which led to passage of the Massachusetts law and which are now causing other states to act will continue to exert their effect until a more durable solution is found.

Health Services Accessibility↗
PubMed1987

Application of the role delineation project "Framework" to a professional preparation program.

Using the Framework for the Development of Competency-based Curricula for Entry Level Health Educators, the health education faculty at the University of Alabama at Birmingham reviewed and modified their undergraduate health education professional preparation program. Efforts focused on the five steps of preparation and study, review and organization of Framework subcompetencies, organization of Framework subcompetencies into potential courses, placement of objectives for courses, and revision of schedule and sequence for professional preparation courses. The process produced seven core courses to be required of all health education majors. A master list of subcompetencies and objectives also was developed. Faculty perceived several benefits from participating in the project.

Alabama↗
PubMed1991

[Delineation of the professional role of health education specialists: a technical proposal].

The responsibilities, competencies and subcompetencies of the Health Education Specialists of the State Health Department of S. Paulo are assessed in this study with a view to verifying the agreement, or otherwise, between the proposals for the technical activity of these health professionals in Brazil and in the United States. With this end in view the document entitled "A Framework for the Development of Competency-based Curricula for Entry--level Health Education" was utilized as the basis for the questions included in the questionnaires submitted to health educators. The results describe the degree of importance attributed to the technical responsibilities and the frequency with which these are performed in the service network of the State Health Department of S. Paulo, Brazil.

Brazil↗
PubMed1990

Clinical nursing.

Today clinical nursing in South Africa is at the crossroads. Many of its best practitioners are lured into management and education, where direct patient contact may be minimal or non-existent. Two reasons for this brain-drain are expounded. Furthermore, a more satisfactory and challenging career structure in clinical nursing is suggested as one possible solution. The educational preparation of nurse clinicians in essential life-skills also needs further attention. The Biomatrix approach is modified and applied to nursing education in an attempt to explain the need for nursing students to learn within a framework that generates self-actualisation, competence and adequate feedback.

Career Mobility↗
PubMed1987

Assessing staff competency.

In the absence of a national credentialing center for nursing and in the interest of ensuring competencies, Forbes Regional Health Center has developed a framework for internal credentialing. This framework, while initiated in a specialty area, has application to all areas of acute care including the medical-surgical areas. Program development within this framework provides a consistent, structured method of documenting selected clinical proficiencies and facilitates the achievement of individual learning needs.

Clinical Competence↗
PubMed1991

Teaching clinical ethics in the residency years: preparing competent professionals.

Formal training in clinical ethics must become a central part of residency curricula to prepare practitioners to manage the ethical dimensions of patient care. Residency educators must ground their teaching in an understanding of the conceptual, biomedical, and psychosocial aspects of the important ethical issues that arise in that field of practice. Four aspects of professional competence in clinical ethics provide a useful framework for curricular planning. The physician should learn to: (1) recognize ethical issues as they arise in clinical care and identify hidden values and unacknowledged conflicts; (2) think clearly and critically about these issues in ways that lead to ethically justifiable courses of action; (3) apply those practical skills needed to implement an ethically justifiably course of action; and (4) judge when the management of a clinical situation requires consultation with individuals or institutional bodies with additional expertise or authority. We argue that these practical goals can be accomplished with a relatively modest emphasis on the theoretical aspects of medical ethics.

Bioethical Issues↗
PubMed2026

Competing subclones and fitness diversity shape tumor evolution across cancer types.

MOTIVATION: Intratumor heterogeneity arises from ongoing somatic evolution and complicates cancer diagnosis, prognosis, and treatment. Reconstructing evolutionary dynamics typically requires spatiotemporal samples, which are often unavailable in clinical settings. Computational approaches that can infer tumor evolutionary history from single-timepoint bulk sequencing data remain limited. RESULTS: We present estimating evolutionary events through single-timepoint sequencing (TEATIME), a novel computational framework that models tumors as mixtures of two competing cell populations: an ancestral clone with baseline fitness and a derived subclone with elevated fitness. Using cross-sectional bulk sequencing data, TEATIME estimates mutation rates, timing of subclone emergence, relative fitness, and number of generations of growth. To quantify intratumor fitness asymmetries, we introduce a novel metric-fitness diversity-which captures the imbalance between competing cell populations and serves as a measure of functional intratumor heterogeneity. Applying TEATIME to 33 tumor types from The Cancer Genome Atlas, we revealed divergent as well as convergent evolutionary patterns. Notably, we found that immune-hot microenvironments constraint subclonal expansion and limit fitness diversity. Moreover, we detected temporal dependencies in mutation acquisition, where early driver mutations in ancestral clones epistatically shape the fitness landscape, predisposing specific subclones to selective advantages. These findings underscore the importance of intratumor competition and tumor-microenvironment interactions in shaping evolutionary trajectories, driving intratumor heterogeneity. Lastly, we demonstrate that TEATIME-derived evolutionary parameters and fitness diversity offer novel prognostic insights across multiple cancer types. AVAILABILITY AND IMPLEMENTATION: R implementation of TEATIME is available on GitHub (https://github.com/liliulab/TEATIME) and Zenodo (https://zenodo.org/records/17422174).

Neoplasms↗
PubMed2026

Tumor evolution shapes metastatic competence in colorectal cancer.

In this issue of Cancer Cell, Manca et al. investigate the genomic evolution and metastatic tropism of over 7,000 colorectal cancers. Integrating primary tumor location, genomic alterations, and clinical variables, they reveal how distinct patterns of tumor evolution shape metastatic competence and impact organ tropism, offering a framework to refine surveillance.

Humans↗
PubMed1985

Crystallographic structure of an active, sequence-engineered ribonuclease.

X-ray diffraction methods were used to test a synthetic-modeling approach to the sequence engineering of bovine pancreatic ribonuclease. A model of RNase S-peptide (residues 1-20), having a simplified amino acid sequence but retaining elements deduced to be essential for conformation and function, was previously synthesized and found to form a catalytically active and stable complex with native S-protein (residues 21-24). We have now obtained a 3-A-resolution electron density map of this semisynthetic complex which reveals that the conformation of model peptide closely mimics that of native S-peptide, as intended by sequence design. Some small differences from the native structure are observed: Glu-2 and Arg-10 of the model complex are not close enough to form a salt bridge, the position of the His-12 imidazole ring is slightly shifted in the active site, and the peptide's amino terminus is reoriented. Nonetheless, the major structural features predicted to be essential by computer-aided peptide-design analysis are preserved in the model peptide portion of the complex. These include (i) the alpha-helical framework involving residues 3-13, (ii) the catalytically competent orientation of His-12, and (iii) complex-stabilizing non-bonding interactions involving Phe-8 and Met-13 of S-peptide and hydrophobic residues in the cleft region of S-protein. Further, sequence simplification has not introduced any non-native, potentially stabilizing contacts between the model peptide and S-protein. The results emphasize the usefulness, in redesigning native proteins, of categorizing sequence into residues providing conformational framework and those determining intra-and intermolecular surface recognition.

Amino Acid Sequence↗
PubMed1992

Effect of pregraduate preceptorship experience on development of adaptive competencies of baccalaureate nursing students.

Kolb's (1984) theory of experiential learning was used as a framework to study 50 baccalaureate nursing students' perceptions of the contributions of a senior preceptorship experience to the development of adaptive competencies. Nursing learning environments were thought to contribute most to divergent and convergent competencies, reflecting the importance of both people-oriented and scientific skills in nursing. The preceptorship had a significant impact on most learning competencies. Significant increases occurred in competencies considered not important for nursing by students prior to the experience, e.g., assimilative competencies such as testing theories and ideas, and accommodative competencies such as leading and influencing others. These results support the notion of further research of nursing learning environments from the experiential learning perspective.

Adaptation, Psychological↗