Dialogical Research in Supervision: Practical Guidelines from Experienced Supervisors in Family Therapy,Child Protection,and Specialty Mental Health Services

This two‐year qualitative participatory research project examines practical guidelines for supervision. Sixteen experienced supervisors across professional settings of family therapy, child protection, and specialty mental health services in the geographical regions of Northern Norway and Northern Sweden outline four main practical guidelines in supervision based on their supervisory practices: (1) elaborating an agreed‐upon contract; (2) exploring potential formats; (3) exploring contents; (4) acknowledging responsibility for process and dilemmas. Participants summarised how they generated mutual growth in supervisory relationships, while being respectful of the first‐person perspective of supervisees. The study challenges pre‐dominating guidelines about deficit‐ or developmental stage‐oriented supervision. It illustrates reflecting processes and a polyphonic orientation in supervision by welcoming diversity, wondering, and tolerance for the not‐yet‐decided among involved persons in a mutual exploration and calibration of relevant knowledge. It outlines a dialogical research for sharing, exploring, and questioning knowledge as beneficial for whom, told by whom, and evaluated by whom.     

Estimates of subgroup treatment effects in overall nonsignificant trials: To what extent should we believe in them?

In drug development, it sometimes occurs that a new drug does not demonstrate effectiveness for the full study population but appears to be beneficial in a relevant subgroup. In case the subgroup of interest was not part of a confirmatory testing strategy, the inflation of the overall type I error is substantial and therefore such a subgroup analysis finding can only be seen as exploratory at best. To support such exploratory findings, an appropriate replication of the subgroup finding should be undertaken in a new trial. We should, however, be reasonably confident in the observed treatment effect size to be able to use this estimate in a replication trial in the subpopulation of interest. We were therefore interested in evaluating the bias of the estimate of the subgroup treatment effect, after selection based on significance for the subgroup in an overall “failed” trial. Different scenarios, involving continuous as well as dichotomous outcomes, were investigated via simulation studies. It is shown that the bias associated with subgroup findings in overall nonsignificant clinical trials is on average large and varies substantially across plausible scenarios. This renders the subgroup treatment estimate from the original trial of limited value to design the replication trial. An empirical Bayesian shrinkage method is suggested to minimize this overestimation. The proposed estimator appears to offer either a good or a conservative correction to the observed subgroup treatment effect hence provides a more reliable subgroup treatment effect estimate for adequate planning of future studies.     

A Bayesian sequential design with binary outcome

Several researchers have proposed solutions to control type I error rate in sequential designs. The use of Bayesian sequential design becomes more common; however, these designs are subject to inflation of the type I error rate. We propose a Bayesian sequential design for binary outcome using an alpha‐spending function to control the overall type I error rate. Algorithms are presented for calculating critical values and power for the proposed designs. We also propose a new stopping rule for futility. Sensitivity analysis is implemented for assessing the effects of varying the parameters of the prior distribution and maximum total sample size on critical values. Alpha‐spending functions are compared using power and actual sample size through simulations. Further simulations show that, when total sample size is fixed, the proposed design has greater power than the traditional Bayesian sequential design, which sets equal stopping bounds at all interim analyses. We also find that the proposed design with the new stopping for futility rule results in greater power and can stop earlier with a smaller actual sample size, compared with the traditional stopping rule for futility when all other conditions are held constant. Finally, we apply the proposed method to a real data set and compare the results with traditional designs.     

A simulation study of methods for selecting subgroup‐specific doses in phase 1 trials

Patient heterogeneity may complicate dose‐finding in phase 1 clinical trials if the dose‐toxicity curves differ between subgroups. Conducting separate trials within subgroups may lead to infeasibly small sample sizes in subgroups having low prevalence. Alternatively,it is not obvious how to conduct a single trial while accounting for heterogeneity. To address this problem,we consider a generalization of the continual reassessment method on the basis of a hierarchical Bayesian dose‐toxicity model that borrows strength between subgroups under the assumption that the subgroups are exchangeable. We evaluate a design using this model that includes subgroup‐specific dose selection and safety rules. A simulation study is presented that includes comparison of this method to 3 alternative approaches,on the basis of nonhierarchical models,that make different types of assumptions about within‐subgroup dose‐toxicity curves. The simulations show that the hierarchical model‐based method is recommended in settings where the dose‐toxicity curves are exchangeable between subgroups. We present practical guidelines for application and provide computer programs for trial simulation and conduct.     

Colorful Disclosures: Identifying Identity-Based Differences and Enhancing Critical Consciousness in Supervision

ABSTRACT

Managing microaggressions and marginalizing experiences while negotiating the ongoing oppression that occurs in micro, mezzo, and macro settings can be particularly challenging for clinicians of color. Thus, supervision with clinicians of color must include affirmation, empowerment, and exploration of the intracultural/intercultural dynamics inherent in the treatment-providing process and clinical supervision. Through case studies, autoethnographic studies of our supervision experiences, and interviews with supervisors and supervisees, we reflect on how axes of identity, including race, power, and privilege, inform practitioners’ clinical lenses and affect their vulnerability in treatment and the clinical supervision dyad. Special attention is placed on the clinical supervisor–clinician–client triad (the triple process) and the interpersonal dynamics of cultural sensitivity, cultural humility, and authentic responsiveness that supervisors aim to model and cultivate in the supervisory relationship. In addition to sustaining clinical growth for clinicians of color, adding this level of complexity to supervision supports equity in direct clinical practice, enhancing efficacy outcomes for clients and communities. Recommendations and pedagogical strategies are offered to support supervisors in initiating difficult dialogues and shifting the paradigm to promote this transformational perspective.     

Unifying CRM and EWOC designs for phase I cancer clinical trials

The main goal of phase I cancer clinical trials is to determine the highest dose of a new therapy associated with an acceptable level of toxicity for the use in a subsequent phase II trial. The continual reassessment method (CRM) [O’Quigley, J., Pepe, M., Fisher, L., 1990. Continual reassessment method: a practical design for phase I clinical trials in cancer. Biometrics 46, 33–48] and escalation with overdose control (EWOC) [Babb, J., Rogatko, A., Zacks, S., 1998. Cancer phase I clinical trials: efficient dose escalation with overdose control. Statist. Med. 17 (10), 1103–1120] are two model-based designs used for phase I cancer clinical trials. A few modifications of the (original) CRM and EWOC have been made by many authors. In this paper, we show how CRM and EWOC can be unified and present a hybrid design. We study the characteristics of the approach of the hybrid design. The comparisons of the three designs (CRM, EWOC, and the hybrid design) are presented by convergence rates and overdose proportions. The simulation results show that the hybrid design generally has faster convergence rates than EWOC and smaller overdose proportions than CRM, especially when the true maximum tolerated dose (MTD) is above the mid-level of the dose range considered. The performance of these three designs is also evaluated in terms of sensitivity to outliers.     

神经内科临床见习教学中几种方法的应用及体会

为适应现代社会对医学人才的要求,在临床教学中应注重对学生能力的培养。结合神经内科临床见习教学,进行了一系列的探索和实践,利用PBL教学模式,借助多媒体等辅助教学工具,采用教与学互动的教学方法,充分调动学生学习积极性、训练正确的临床思维方法,提高了学生分析和解决问题的能力。     

法律诊所式教育可行性对策思考

法律诊所式教育在弥补了传统法学教育的弊端的基础上近年在中国获得了飞速的发展。但是,对其“本土化”的争论引起了人们的思考。法律诊所式教育应该如何适用,影响法律诊所式教育可行性的原因有哪些,本文基于此,结合中国的现实,提出了相应具有实际意义的解决对策,期望对中国的法律诊所式教育的发展做出一定的贡献。     

构建医学生口腔临床技能和实践能力培养新模式

目的:建立培养学生口腔临床技能和实际工作能力的教学模式。方法:组成以训练临床综合技能为主的临床口腔医学课程群;开展一、二年级以接触社会、接触患者为主的社会实践;三、四年级以仿真头模操作为主的综合实验训练和口腔专业课学习兴趣小组;五年级以毕业实习为主的综合临床技能培养的教学模式。结果:提高了学生口腔临床技能和实际工作能力,患者对实习医生的满意率明显提高,学生的研究生录取率明显提高,毕业生当年就业率达100%,用人单位满意。结论:建立新型的教学模式是培养学生口腔临床技能和实际工作能力的可行方法。     

骨科教学改革的对策与思考

以骨科教学为例,分析了当前教学中的困惑和思考①落后的教材与日益更新的诊疗技术;②应试教育的现实与素质教育的理想;③传统教学手段的根深蒂固与先进教学方法的大胆尝试;④"灌输式”教学的质疑与"创新性”教学的期盼.作者提出了对策.