How do university training and subsequent practical experience affect expertise in clinical psychology? To answer this question we developed methods to assess psychological knowledge and the competence to diagnose, construct case conceptualizations, and plan psychotherapeutic treatment: a knowledge test and short case studies in a first study, and a complex, dynamically evolving case study in the second study. In our cross-sectional studies, psychology students, trainees in a certified postgraduate psychotherapist curriculum, and behavior therapists with more than 10 years of experience were tested . Clinical knowledge and competence increased up to the level of trainees but unexpectedly decreased at the level of experienced therapists. We discuss the results against the background of expertise research and the training of clinical psychologists (in Germany). Important factors for the continuing professional development of psychotherapists are proposed. In our studies we examined in detail the degree to which expertise in clinical psychology and psychotherapy develops at different points in the course of education at university level, training at the postgraduate level, and subsequent practical experience. Based on psychotherapy research and findings of cognitive science on expertise in general we developed instruments for assessing knowledge in clinical psychology as well as psychotherapeutic competencies. In two cross-sectional studies, German university students at different stages of their studies, graduate therapist trainees, and experienced psychotherapists were assessed.In the following section, we provide a brief overview of expertise research with a special focus on expertise in medicine as a relatively well explored neighboring field. Moreover, results from psychotherapy research on clinical expertise are summarized.Research on the nature of expertise has attracted a great deal of attention since the 1960s until the present  as we recruited our sample from a population of students and postgraduates studying or having studied this curriculumIn Germany since 1999, psychologists intending to work as Psychological Psychotherapists are legally required to engage in a certified postgraduate training program of 3–5 years. These postgraduate education and training programs comprise theoretical and practical units as well as self experience or undergoing therapy. The theoretical units consist of psychotherapy-related lessons, e.g., cover various psychological disorders or elements of behavior therapy. In the practical units, trainees intern in a certified psychiatric ward as well as in a psychotherapeutic institution practicing to adapt their theoretical knowledge and competencies to individual cases. Once they have learned the basics they treat patients under supervision, mostly in outpatient settings. Psychologists who have finished this additional training are then legally allowed to work independently with patients. It should be noted that therapists who had completed their training before 1999 did not have to undergo such a full certified training.But what is known already about development of expertise in clinical psychology and psychotherapy? Research on expertise development in clinical psychology and psychotherapy is still scarce  and knowledge of how to apply basic psychological knowledge to clinical psychology would reach its maximum in the third year of university studies (intermediate students), whereas clinical knowledge and clinical competencies would increase steadily with continuing formal education during the years of studying psychology (up to advanced students). Accordingly we assumed an increase of higher-order concepts in recalling relevant information of case studies comparable to the knowledge encapsulations found in the medical domain , 15 graduate trainee therapists (Level 4), and 15 experienced therapists (Level 5) participated in our study. Novice and intermediate students were on average 24 years old, advanced students 25 years, postgraduate trainee therapists 31 years, and the experienced therapists 49 years. As psychology is a popular subject for women in Germany, our sample was mainly female: 85% of the novice students were female, 80% of the intermediate students, 87% of the advanced students, 80% of the trainee therapist, and 73% of the experienced therapists.via a special search engine for physicians and therapistsAll participants received a small financial compensation for their voluntary participation. Students and trainee psychotherapists were recruited during lectures and workshops. The psychotherapists were found For an overview of the dependent variables please see Tables The questionnaire was comprised of multiple-choice questions and open-format questions on (a) basic psychological knowledge, (b) knowledge about how to apply basic psychological knowledge to clinical psychology, and (c) clinical knowledge. (a) Basic psychological knowledge was assessed by five multiple-choice questions and one open-format question . (b) Knowledge regarding the application of basics to clinical psychology, e.g., Mowrer’s two-factor theory of avoidance learning was assessed with three multiple-choice questions, and (c) knowledge about clinical psychology was assessed with four multiple-choice questions and one open-format question. For the multiple-choice items, we measured the percentage of correctly answered items per section. To analyze the answers to the open-format questions, we counted the correct statements based on model solutions and also counted the number of technical terms used.Up to now, I was more or less able to avoid unpleasant situations, in my personal life too, by simply leaving when I couldn’t bear it. I seldom attended lectures or courses; nevertheless I managed my studies with acceptable grades. Everybody who does not regularly give presentations is nervous before presenting but with me this is really extreme and I feel physically ill. But that is not my main problem. My sweating makes me sick. I do not sweat in comfortable situations, such as when I am alone at home or with my best friends. But if there is just one stranger with us it starts immediately. My hands turn blue and wet; my shirt gets soaked in cold, clammy and malodorous sweat. I have already consulted a medical practitioner; there are no physiological causes for this. For professional reasons this must stop, I work as a representative.Outsiders see me as a self-confident and competent person; this seems totally absurd to me because I am so nervous that besides the sweating my muscles start shaking (from the legs up to the face). If other people are present, my facial skin turns as pale as ash, my skin gets sweaty, after a while my hair becomes greasy and I feel scruffy even though I am not. Lately, I try to behave confidently, to go up to a person and not to wait till I have to. But afterwards I am so exhausted that I can not stand it any longer and I am exhausted.In a more indirect way, and similar to studies in the domain of medicine , diagnose, and explain the disorder (explanation phase). In the recall phase, we assessed the amount of correctly recalled statements by comparing recalled statements to presented statements. We assessed the amount of higher-order concepts used by counting the recalled statements that summarized more than one statement presented in the case study. For the diagnosis, a score from 0 (no or wrong diagnosis) to 1.0 (correct and elaborated diagnosis) was assigned. For the explanations we measured the amount of correct statements by comparing them to a model solution compiled by the first author based on textbook knowledge. The model solution included explanations of different positions within psychological therapy, so that in some cases different answers could be counted as correct statement.All answers except the automatically evaluated multiple-choice questions were analyzed by the first author. In order to measure interrater-reliability, 20 randomly selected reactions to the open-format questions and the case studies were independently assessed by a trained research assistant. All intraclass-correlations  exceeded the criterion of 0.7  = 2.55, p < 0.01, η2 = 0.36]. The MANOVA shows overall substantial differences between the five groups. Subsequent ANOVAs described below were conducted to test in detail our hypotheses. We computed four a priori contrasts, of which only significant or marginally significant contrasts are reported. The first contrast compared novice students to intermediate students, the second contrast compared intermediate students to advanced students, the third contrast compared advanced students to trainee therapists, and the fourth contrast compared trainee therapists to experienced therapists. Cohen’s d is reported as a measure of effect size for the contrast analyses.For all statistical analyses we adopted a significance level of α = 0.05. We conducted a multivariate analysis of variance (MANOVA) with the dependent variables comparing the five groups of participants representing different levels of experience .There was no significant difference regarding the overall time participants of the five groups spent completing the assessment . With regard to the open-format question, the ANOVA on the number of correct statements was not significant  but the ANOVA on the number of technical terms used revealed a significant effect . Supporting Hypothesis 1 novice students scored the highest in all three measurements. In line with Hypothesis 3 experienced therapists scored rather low on the multiple-choice questions and the amount of correct statements in the open-format question. But it has to be noted that none of the four a priori contrasts reached significance.Regarding basic psychological knowledge, the ANOVA approached significance for the multiple-choice questions . As assumed in Hypothesis 1, novice students scored significantly lower than intermediate students . There was no significant difference regarding the applied knowledge from intermediate students up to the therapists (in line with Hypothesis 2 and 3).Concerning the knowledge of how to apply basic psychological knowledge to clinical psychology, the ANOVA revealed significant differences between the groups , with trainee therapists outperforming even the advanced students . This result is in accordance with Hypotheses 1 and 2. With regard to the open-format question, the groups likewise differed significantly regarding both the amount of correct statements  and the application of technical terms . Figure t = 2.8, p < 0.01, d = 0.89]; technical terms: t = 2.5, p = 0.02, d = 0.78. This result is in line with Hypothesis 1. Consistent with Hypothesis 2, regarding correct statements, the difference between advanced students and trainees was also significant . However, contrary to our assumptions in Hypothesis 3, on both variables, experienced therapists scored lower than trainees ; technical terms: t = 3.4, p < 0.01, d = −1.23.In terms of clinical knowledge, the five groups differed significantly on the multiple-choice questions  and the amount of recalled statements . Regarding the use of higher-order concepts, as expected in Hypothesis 1 and 2, there was an increase up to the level of trainee therapists but contrary to Hypothesis 3 no increase (but rather some decrease) at the level of experienced therapists. Participants recalled about the same amount of statements from the level of novice up to the trainee therapists, while the experienced therapists recalled fewer statements than the trainee therapists .Means and standard deviations for the dependent variables of Case Study 1 are depicted in Table F = 6.7, p < 0.01, η2 = 0.25]. Concerning Hypotheses 1 and 2, diagnosis improved up to the level of intermediate students but then leveled off . There was no evidence for Hypothesis 3, increase in diagnostic competencies, at the level of experienced therapists.In terms of the quality of the diagnosis, one of the measures of clinical competence, the groups differed significantly . Again, the already familiar picture was found, with an increase in correct statements up to the trainees’ level , d = 0.67 but no increase at the experienced therapists level.With regard to explanation of diagnosis, a second measure of clinical competence, the groups differed significantly in the amount of correct statements  but as expected there was a difference in the amount of higher-order concepts used . At the level of advanced students, the number of higher-order concepts significantly increased , leveled off at the level of trainee therapists, and showed no further increase at the level of experienced therapists.Means and standard deviations for Case Study 2 are depicted in Table F = 3.2, p = 0.02, η2 = 0.14]. In accordance with Hypothesis 1 diagnosis improved at the level of intermediate students  but then leveled off which was not consistent with our hypotheses.In terms of the quality of the diagnosis, the groups differed significantly  which was again mainly due to the difference between novices and intermediates: t = 3.5, p < 0.01; d = 1.09). Overall the data showed an increase up to the trainees (Hypothesis 1 and 2) and then no further increase for the experienced therapists, contrary to Hypothesis 3.With regard to explanations, the groups differed significantly in relation to the amount of correct statements  now family situation, ok, so there seem to be problems after all, so he’s often checking, whether he’s saying the truth, well maybe he somehow has like obsessive thoughts, compulsive checking or hallucinations […]Subject 6, a student, diagnosed wrongly:(b)[…] for the borderline- diagnosis, what do we have here? We have the inner emptiness, we have suicidality, we have the self-harming behavior, at least with extreme sports, we have the suicidality, also this fear of abandonment, impulsive behavior. Of course we also have, that he even in his self-image, could be such an indication for such an unstable self-image, too, in that he suddenly thinks, they all would consider him to be antisocial and things like that, and also these breakdowns […]Subject 9, a the trainee therapist, justified his correct diagnosis with symptoms described in the case study: (c)[…] that is this narcissistic disorder, I would pin that on him additionally, because it emerges from this presumed mother-relationship. From experience all sons, who with a single superior mother, who maybe also have depressive anxious traits, in fact, have in the background such a narcissistic disorder [investigator: asks for explanatory statement] the anger. […]Subject 4, an experienced therapist, diagnosed wrongly due to deficient clinical knowledge: We checked the statements of the participants of our study for the main components of a case conceptualization […] then there increasingly are tantrums, especially, when he feels criticized, which I find consistent with the hypothesis now in a sense, because I would have assumed, at work, too, situations of criticism or situations of social degradation trigger a reaction in him, which are cause for the colleagues’ bullying […]Subject 11, a student, showed difficulties regarding the integration of information: (b)[…] so one has to look now, whether out of this somehow a life pattern has somehow formed, that somehow in relationships again and again losses happen to him or that he leaves people or is unstable in relationships, but no idea, I have to look […]Subject 9, a trainee therapist, predicted problems that arose later: (c)[…] tense, all these relationships are somehow tense […]Subject 2, an experienced therapist, focused on a relevant factor, interpersonal relationships but reflected it on a superficial level: Three of the advanced students described therapeutic approaches that would likely lead to a termination of therapy such as choosing a confrontational approach. One of the advanced students described an adequate treatment plan; however, it remained on a rather general level. Although some trainee therapists showed deficits regarding the correct diagnosis (see above), all of them described adequate treatment plans, e.g., as defined by dialectical-behavior therapy for borderline personality disorders. They emphasized the unconditional positive regard and the need to proceed cautiously and slowly. With experienced therapists we again obtained a mixed picture. About half of the therapists described adequate therapeutic approaches and also considered the therapeutic relationship. The other half described rather general approaches. These results on the quality of the treatment plans again are in line with Hypothesis 2 but not with Hypothesis 3. Four exemplary statements are provided for illustrative purposes.(a)[…] I would explicitly address my role, meaning that I am not prepared, to collude with him, but rather, that I expect, that he works on himself, because otherwise it would again go in the direction of the therapy having to fail, precisely because he shifts the blame on others and doesn’t look for it [the blame] in himself, like in the current example, has been the case with the layoff as well […]Subject 11, a student, proposed an unsatisfactory treatment plan although the complete case study was already presented: (b)[…] I’d be careful in any case, I would very much keep it in the back of my mind, that in any case the relationship is very important and I would pay a lot of attention to his not having the feeling to be seen as inferior, deficient, but rather really look, at what kind of resources, options he does have […]Subject 7, a trainee therapist, proposed a satisfactory treatment: (c)[…] this thing with the two-timing would be the critical thing, so like dialectical so to speak, that one says, that is totally okay, how he is, that is legitimate, one can infer that, how he is, and although it is okay how he is, it would probably nevertheless also be sensible, to change, and that that I think, that is just important, that one takes that along from the get-go, so to take him seriously on the one hand in his in his so-being, yeah so whatever there is now and to question that, one can do that, when the relationship has grown, the therapeutic relationship thus has to be resilient […]Subject 6, an experienced therapist also proposed a satisfactory treatment: (d)[…] he’d have to go to a man, I’d first of all say that […] I don’t think, that a therapist can do anything now, that could lead to, with this patient, as it were, that he sticks with his problems, because the problem in his precisely in his case is difficult […] I wouldn’t know at the moment, how I could solve that, I have no idea to this end, I’d have to go to supervision, or ask my colleagues […]Subject 2, also an experienced therapist, would refer the patient to another therapist: In Study 2, we found distinct differences between the three examined levels of clinical experience. The groups differed regarding the quality of diagnosis, case conceptualizations, as well as planning of the treatment. Consistent with Hypothesis 2, advanced university students had more difficulties in dealing with the provided complex clinical case study compared to the trainee therapists, but they were able to diagnose the major depression and to plan adequate general treatment for it. They failed in relation to making a sufficiently sophisticated and complex diagnosis and treatment plan for borderline personality disorder and addiction. Regarding the experienced psychotherapist, we obtained mixed results that are not in line with Hypothesis 3; some of them worked on the case study in an almost exemplary manner; they integrated the provided information and supported their diagnoses with symptoms described in the case study. However, other experienced therapists failed to develop an individual case conceptualization, did not diagnose correctly, or failed to plan a treatment that was based on the information described in the case study. As in our first study and consistent with Hypothesis 2, the trainee therapists achieved the best results. They integrated the described symptoms into adequate diagnoses, developed meaningful case conceptualizations, and planned satisfactory treatments.We assessed the effects of university training, postgraduate psychotherapist training, and clinical experience on expertise in clinical psychology. A central characteristic of our approach was to ensure that the expertise in our research group comprised competencies in the assessment of cognitive processes as well as expertise in clinical psychology and psychotherapy. Thus, our research group consisted of both cognitive scientists and researchers from clinical psychology. This collaboration enabled the construction of relevant materials that partly bridged the gap between directly assessing knowledge about facts and concepts and indirectly assessing procedural knowledge for solving complex and dynamically changing clinical cases. We consider this multi-method approach to be a clear advantage in expertise research in domains like clinical psychology.Knowledge about facts, concepts, and procedures has been shown to be one of the main factors discerning experts and novices in different fields  in more detail.Effects of studying psychology at the university on expertise (Hypothesis 1): in the first 3 years of studying psychology, university students learn about basic concepts and principles of psychology and their application. Consequently, students at these levels outperformed participants of the other levels on these variables. Later on in their course of studies, students who chose clinical psychology as their main focus showed clear improvements in clinical knowledge. They also were able to provide correct diagnoses in short case studies. However, the case-based interview revealed that they failed to integrate information in a complex and dynamically changing situation leading to incomplete diagnoses and inadequate treatment planning.Effects of postgraduate therapist training on expertise (Hypothesis 2): since 1999, after attaining the Master’s or Diploma degree, future psychotherapists must engage in a certified postgraduate training program comprising theoretical clinical courses, practical training, and self experience. In both of our studies, trainee therapists achieved the best results on nearly all measured variables. In particular, our results indicate a further increase in clinical knowledge and competencies. Trainee therapists provided high quality diagnoses, coherent case conceptualizations, and adequate treatment planning. We conclude that the training program is very successful in substantially enhancing clinical competencies.Effects of more than 10 years of practical experience on expertise (Hypothesis 3): the experienced therapists who participated in our studies had been working for at least 10 years in a clinical setting. They had not engaged in the above described therapist training but they had also completed their university studies with a “Diploma” degree and had completed a further but less standardized therapist training. At the level of these experienced therapists, our results point to a decrease both in basic psychological knowledge and knowledge of how to apply basics to clinical. Surprisingly, we observed even some decrease in clinical knowledge in contrast to Hypothesis 3, which stated that experienced therapists show more clinical knowledge than the less experienced groups. The decrease of clinical knowledge at the level of experienced therapists seems to contradict findings in other domains, in particular medicine  both studies were cross-sectional studies, examining different cohorts. Our sample of experienced therapists started working as psychotherapists before the psychotherapists’ law came into effect in 1999. Thus, compared to the sample of trainee therapists, the experienced therapists had completed a less stringent therapist training after completing their university studies. (b) University studies in psychology are now organized such as to lead to a Bachelor’s and a Master’s degree. The participants in our studies still graduated with a diploma degree. But as the Master’s and the “Diploma” degrees are comparable in content, methods, and process, it seems safe to assume that the obtained results would be similar with the new sequence of degrees. (c) The studies were conducted in a non-psychotherapeutic setting. Thus, the findings cannot be generalized directly to the behavior in such a setting. (d) The approach of case-based interviews is very time-consuming regarding analysis and evaluation of data. However, further studies are needed to replicate our results with a bigger sample size. (e) It must also be noted, that personality disorders were not commonly included in many training programs until recent times and clinical knowledge about personality disorders has developed a lot over the past 10 years.Similar to research in other domains, our studies revealed that in the domain of clinical psychology experience does not automatically translate into expertise  appropriate courses. However, in the domain of medicine, it was found that self-assessments barely correlate with outcome criteria Davis, . The proOur studies reveal that university training and therapist training promote the development of expertise in clinical psychology and psychotherapy. However, the trainee therapists rather than the experienced therapists did best in our studies. We conclude that at least under the given conditions a central component of evidence-based practice in psychology APA, , namely The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Despite the recent rapid development of policies to counteract physical inactivity (PI), only a small number of systematic analyses on the evolution of these policies exists. In this article we analyze how PI, as a public health issue, “translates” into a policy-making issue. First, we discuss why PI has become an increasingly important public health issue during the last two decades. We then follow Guy Peters and conceptualize PI as a “policy problem” that has the potential to be linked to policy instruments and policy impact. Analysis indicates that PI is a policy problem that i) is chronic in nature; ii) involves a high degree of political complexity; iii) can be disaggregated into smaller scales; iv) is addressed through interventions that can be difficult to “sell” to the public when their benefits are not highly divisible; v) cannot be solved by government spending alone; vi) must be addressed through a broad scope of activities; and vii) involves interdependencies among both multiple sectors and levels of government.We conclude that the new perspective on PI proposed in this article might be useful and important for i) describing and mapping policies to counteract PI in different contexts; ii) evaluating whether or not existing policy instruments are appropriate to the policy problem of PI, and iii) explaining the factors and processes that underlie policy development and implementation. More research is warranted in all these areas. In particular, we propose to focus on comparative analyses of how the problem of PI is defined and tackled in different contexts, and on the identification of truly effective policy instruments that are designed to “solve” the PI policy problem. Public health scientists are increasingly adopting physical activity as a research topic. This trend is borne out in the literature. A Medline search reveals an almost fourfold increase over the past two decades in the number of articles containing the phrase “physical activity,” from 2,286 articles published between 1991 and 2000 to 8,863 articles published between 2001 and 2010.Underlying the increased importance of physical activity as a concept are high levels of sedentary behaviors in many countries ,2 and moNational and international public health policies that tackle PI are also rapidly developing. The WHO’s “Global Strategy on Diet, Physical Activity and Health”  sends a A systematic analysis of the evolution of physical activity policies would be highly warranted, particularly as evidence indicates that physical activity policies are either underdeveloped or require improvement in many countries -12. To dAgainst this backdrop, we suggest that it is time to develop more specific and theory-based approaches to the analysis of policies counteracting PI. Such approaches should include exploration of the logic associated with the process of policy-making. Specifically, investigations should focus on how PI, as a public health issue, “translates” into an issue of policy-making, in other words how it is defined, viewed and solved as a policy problem. In his discussion of “The Problem of Policy Problems”, Peters proposes a set of seven variables that can be used to define and characterize policy problems .This article first briefly indicates some key characteristics of PI as a public health issue. It then introduces the concept of policy problems and provides a preliminary description of PI in relation to policy problem characteristics. It concludes that viewing PI as a “policy problem” is an important contribution to research in several respects. First, it provides a useful framework that can help describe and map health promotion policies in different contexts. Second, it can assist in evaluating whether or not existing policy instruments used to promote physical activity are appropriate. Third, it may help investigate the factors and processes that underlie the development and implementation of policies counteracting PI.In the last two decades, PI has become increasingly recognized as an important public health issue. This section addresses five key characteristics that are integral to contextualizing PI as a public health issue. It then discusses how these characteristics affect perceptions and approaches to reducing PI and promoting physical activity. This latter dynamic has an influence on how PI is translated into a “policy problem” in various circumstances.e.g. capabilities to be physically active) and structural issues (e.g. access to infrastructures) [PI’s increasing relevance as a public health issue is closely tied to its role relating to the obesity epidemic as well as non-communicable disease rates (NCDs) like type II diabetes and heart disease , which auctures) -19.Despite increasing efforts to promote physical activity, the prevalence of PI has remained rather stable in most developed nations ,21. It iThe advent of the HEPA concept  in the PI is attributed to a number of determinants. Among them are age, educational attainment , attitudes, enjoyment , social support from family and peers , and the availability of infrastructures and facilities  . Ecologie.g. exercise classes), community-based interventions (e.g. interventions focused on broadly publicizing information over a longer period of time), mass media campaigns, health-care setting interventions (e.g. green prescriptions), policy interventions  and environmental interventions . Reviews of these interventions do indicate that a number of different strategies might need to be combined in order to effectively promote physical activity [There exists a variety of evidence-based interventions to tackle the public health issue of PI -31. Theyactivity .i.e. how different political actors perceive and frame problems according to their preferences and goals [i.e. with attributes that are inherent in the problems themselves. Such a perspective is interesting because it directs attention to potentially successful problem solutions.There exists a substantial body of literature on the role of policy problems within the policy-making process. A major topic in this literature is agenda setting, in other words when and how do public issues become problems that are believed to require public action ,34. Anotnd goals -37. Sevend goals ,38. Howend goals  providesAccording to Peters, defining public issues such as PI as “policy problems” helps to “explicate the relationships between problems and instrument choice” , and mayGiven the well-known relationship between implementing appropriate policy instruments and subsequent policy outcomes , furtherIn the following discussion we engage in Peters’ second stage in Peters' second stage of policy characterization by applying his recommended set of seven variables to PI . These ve.g. health and economic policy).The first variable introduced by Peters is “solubility”. Peters defines it as the degree to which policy problems can actually be solved. He suggests that acute problems may be solved within a “once and for all/finite” amount of time, while chronic problems are more likely to appear and reappear on policy agendas despite the fact that many attempts to provide solutions may have already been made  are easily understood by “the average citizen” [e.g. individual, social and environmental) that may influence changes in sedentary behaviour. Various parties have been known to compete to win the adoption of their favoured models as “the most relevant” frameworks for use in the creation of physical activity policies and interventions. For instance, in her analysis of the Active Living policy in Canada, Bercovitz argued that the rhetoric of “active lifestyle” as a personal choice and individual responsibility was used to conceal structural health inequalities and the retreat of the welfare state from social responsibility for health in times of financial crisis [PI can be characterized as a policy problem with a high degree of political complexity because it involves a variety of sectors, actors and interests. Its programmatic complexity appears comparably low at first sight, at least with respect to its “technical content” . For exacitizen” . PI becocitizen” . These ml crisis .Thus, political and programmatic complexities of a policy problem might also interact. Arguments about the superiority of different multiple causation models might result in political struggles about which interventions should be used to promote physical activity. For example, some political actors might call for mass media campaigns to address psychological factors associated with physical activity behaviour. Since the development of mass media campaigns might also reduce levels of inter-sectoral dependencies (they are more easily developed by a single policy sector), such campaigns might be seen as appropriate. Other political actors, however, might dispute the effectiveness of mass media campaigns and call instead for other kinds of programs. An important example is the CDC in the United States, which found evidence on the effectiveness of stand-alone mass media campaigns to promote physical activity to be insufficient  and recoThe consequences resulting from dealing with policies that maintain high levels of complexity coincide with consequences associated with other variables. For example, PI’s high level of political complexity may lead researchers to the same conclusions as those reached when analyzing PI’s “solubility”. To that end, researchers might conclude in both situations that participatory and collaborative approaches should be used in physical activity promotion policy processes because “policy design efforts should enable processes that are: (1) flexible enough to respond to varying interests; (2) understood by all those involved; (3) defined in terms of specific processes for overcoming stalemate and disagreement” . High poThe question of scale refers to the degree to which a policy problem can be disaggregated into smaller components that are easier to deal with than the problem as a whole. PI does not represent a typical large-scale problem requiring an “all or nothing approach.” It is “susceptible to disaggregation into smaller scales” , and it (i.e. the costs are highly divisible) but only leads to benefits for a specified group , it is theorized to be more difficult to solve than problems that yield widely-distributed benefits.The question of “divisibility” does not so much pertain to the disaggregation of problems into smaller sub-problems  but to the question of how costs and benefits relating to the solution of a policy problem are distributed . For exae.g. health education programs and mass media campaigns). Another potential divisibility issue is that certain public initiatives to promote physical activity might yield benefits mostly for those who are already active (e.g. public subsidies for new sport facilities). A more “divisible” alternative might be the promotion of multi-use infrastructures or broader environmental interventions  that benefit a wider range of people.With respect to PI, many interventions are targeted toward specific sub-populations. While there are often good reasons for this, policies promoting such interventions may be more difficult to “sell” to the public  than policies that support interventions directed at broader populations  , the “BlFinally, “interdependencies” refer to the degree to which policy problems can be solved within one policy domain or by one lone government agency. Peters argues that the “degree of interdependence characterizing any particular problem influences the capacity of government to solve the problem, as well as the range of appropriate policy instruments” .Regarding PI, one can observe a high degree of interdependencies that lead to the involvement of a variety of policy domains, agencies and levels of government: First, there is broad scientific evidence that substantiates the fact that the environment influences physical activity levels, and there is also evidence that substantiates the fact that environment-oriented interventions stimulate physical activity . Thus, iSecond, in many countries, the main responsibility for developing and implementing policies related to PI rests at the regional and local levels. Both the United States and Canada serve as cases in point. In both nations, a considerable percentage of policy-making takes place at regional and local levels . A complThird, responsibility for policy development and implementation quite often extends beyond the public policy sector. For example, in Germany, sport clubs assume a central role in delivering health related physical activity programs.The challenges of “interdependencies” already have been recognized in many policy documents. National physical activity action plans -46,50 eme.g. NGOs), and insufficient assignment of long-term responsibilities and resources [However, despite widespread recognition of the interdependency of PI during policy formulation, countries still often fail to apply adequate policy instruments for inter-sectoral and multilevel policy implementation. The Norwegian Action Plan, for instance, has been selected as a good practice example for physical activity policy in Europe on several occasions. However, a systematic evaluation of the plan revealed a lack of coordinated use of instruments towards common targets across sectors, inadequate adjustment to regional and local actors  of policymaking and thus allows for more development of refreshing perspectives regarding need and choice of policy instruments.First, it provides a framework that can help describe and map policies to counteract PI in different contexts. It is sensitive to the specificities of both PI as a public health issue and generic characteristics of policy problems. Instead of mapping PI-related policies along a set of general dimensions such as nation, sector, and target group, defining PI as a policy problem directs analysis towards truly relevant categories . Several theoretical approaches might be useful in analyzing these processes, for example: i) the Multiple Streams framework [Defining PI as a policy problem using the variables suggested by Peters is an important first step to highlighting the general characteristics of PI as opposed to the characteristics of other major policy problems. Against this conceptual background, it is worthwhile to further investigate how and why the specific definition of PI as a policy problem varies in different policy environments. One important factor of influence pertains to the processes employed in the making of policies  and to compare select contexts with respect to their similarities and differences, thus contributing to a deeper understanding and better explanations about how exactly policy processes and contexts shape the definition of policy problems.Besides comparative research on the general and context-specific definitions of PI as a policy problem, an important next step would be to investigate which solutions, or policy instruments, might be best suited to solve the problem. The ultimate goal of such research would then be to make physical activity promotion policy “truly” evidence-based, as opposed to simply applying the logic of evidence-based interventions to the fundamentally different realm of policy-making .Of course, as Wildavsky and other “realist policy analysts” have emphasized, policy-making may not follow “the rational paradigm”, where problems are defined first and the most appropriate solutions are selected afterwards. In real-world policy-making, “solutions often search for problems” . For exaThis last point also directs attention to an interesting final theoretical consideration, namely the link between policy instruments and physical activity promotion interventions. It can be assumed that certain interventions may only be successfully implemented if they are supported by corresponding policies. For example, an infrastructural intervention involving multiple sectors can only be successful if governmental agencies from all of the sectors are involved in shaping physical activity promotion policy. If this is not the case, inter-sectoral interventions might fail even if they have been shown to be effective in other contexts. Thus, a thorough understanding of PI as a policy problem might not only be useful in identifying better policy instruments, but it also may help achieve a better match between interventions and policies in future physical activity promotion efforts.PI: Physical inactivity.The authors declare that they have no competing interests.AR: Designed the study, developed the outline, contributed to the analysis, and contributed to the writing and revision of the manuscript. KAO: Revised the outline, contributed to the analysis, and contributed to the writing and revision of the manuscript. PG: Revised the outline, contributed to the analysis, and contributed to the writing and revision of the manuscript. DS: Revised the outline, contributed to the analysis, and contributed to the writing and revision of the manuscript. All authors read and approved the final manuscript.


The Institute of Medicine (IOM) recently set out to review the current evidence on links between breast cancer and the environment. Their conclusions, published in a report issued 7 December 2011,Commissioned by Susan G. Komen for the Cure®, a Dallas, Texas–based cancer research advocacy group, the report was prepared by a 15-member panel from academia and community health centers. The panel defined “environment” as any factor that isn’t inherited through DNA and relied on evidence compiled by the International Agency for Research on Cancer and the World Cancer Research Fund International, in addition to findings from the scientific literature.Breast cancer risk factors were divided into 3 categories—established, possible, and biologically plausible—on the basis of the strength of the data, according to panelist Robert Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco. “Established” risk factors were supported by strong human epidemiologic data, in addition to positive results from animal and mechanistic studies. Risk factors were assigned a “possible” status if the available human data were in conflict and a “biologically plausible” status if they were supported solely by animal and mechanistic studies.Remarkably, only a few established risk factors were identified, among them combined hormone therapy with estrogen and progestin, exposure to ionizing radiation (such as that delivered by computed tomographic scans), excess weight in postmenopausal women, and excessive alcohol use. Possible risk factors include nighttime shift work and exposure to secondhand smoke, benzene, ethylene oxide, and 1,3-butadiene. The biologically plausible category is populated mainly by industrial chemicals, including metals, pesticides, and the plastics constituent bisphenol A, which is ubiquitous in consumer products, the environment, and people, and therefore exceedingly challenging to study in controlled epidemiologic studies, according to Hiatt.By emphasizing lifestyle changes in prevention, the IOM distinguished itself from the President’s Cancer Panel (PCP), which in spring 2010 released a headline-grabbing annual reportBut Hiatt says the IOM panel was charged with reviewing the current evidence, not recommending regulatory policy. In most cases, he says, more human data are needed to bolster cause–effect relationships between chemicals and breast cancer. “We usually couldn’t find solid human evidence of effect,” he says. “Either the data wasn’t there or it was conflicting, and we had to make the call based on what we know in 2011.”The chief recommendation of the IOM is that researchers adopt a “life course” approach to studying breast cancer and the environment, with more emphasis on early-life human exposure. “One reason that we might be missing the boat on the human data is that we’re looking at adult women, while carcinogenic effects may result from exposures that happen while the breast is still developing,” Hiatt says. “We know from animal experiments that this is a window of vulnerability to chemical insults.”Along those lines, Hiatt adds, the National Institute of Environmental Health Sciences and the National Cancer Institute are collaborating on the Breast Cancer and the Environment Research Program, which recruits subjects starting at the age of 6 years. The two institutes also collaborate on the Interagency Breast Cancer and Environmental Research Coordinating Committee, a congressionally mandated body currently preparing a comprehensive report on federal research on the environmental and genomic factors related to breast cancer. This report is expected in mid-2012.Michael Thun, vice president emeritus of surveillance and epidemiology research at the American Cancer Society, lauds the IOM report for systematically reviewing the available evidence. “It fills an important gap,” he says. “I agree with its position that we have issues of concern as research needs, but they’re in a different category than well-established risk factors.”Adds Diana Rowden, vice president for survivorship and outcomes at Susan G. Komen for the Cure, “The report shows that women can reduce their breast cancer risk with actionable items undertaken now. And it challenges us to think more about how we explain cancer risk to the general population—about how different factors have their own unique influence on risk. That’s an important takeaway point.”


This 600-page board review book provides an excellent synopsis of infectious diseases. It is divided into 4 sections, each with a questions and answers section: General, Etiologic Agents, Select Major Clinical Syndromes, and Special Hosts and Situations. There are almost 200 questions in the book; however, they are not written in the American Board of Internal Medicine test format. Compared with the bulky binders filled with copies of electronic presentations that I took home from a live board review course, the Mayo Clinic book is a more useful and convenient desk reference.The infectious disease information is presented in a way that facilitates understanding, not just memorization. Although organized differently, the content of the book is comparable to that presented in the live course. Some chapters were exceptional . I showed the book to an infectious disease fellow who passed the boards in 2011 with a score of 99%; that bright young fellow noted that the coverage of infectious diseases in transplant recipients and in patients with hematologic malignancies is “sketchy.”Vibrio vulnificus” among the answer choices). In addition, the book does not cover non–infectious disease syndromes masquerading as infections , which, along with ethics, comprise up to 10% of the examination. The chapter on liver infections left me wanting more help distinguishing various types of viral hepatitis, i.e., hepatitis A–E, from other infectious causes of hepatitis, such as leptospirosis, as well as non-infectious causes of hepatitis. The book seems to have omitted certain important points, such as when vaccine against hepatitis A virus is recommended as a postexposure intervention.In terms of practical examination preparation, the book is not as good as the live course when it comes to training test takers to recognize clues within the test. The book could more explicitly emphasize combinations of clues, or “buzz” words, that should trigger certain associations for the test taker (e.g., if question stem includes “cirrhosis and oysters,” look for “In conclusion, the Mayo Clinic Infectious Diseases Board Review book is an excellent means to solidifying one’s infectious disease knowledge, and it could be a useful as an adjunct review tool. However, in terms of preparing for actual examination-style questions and for assuring that the full breadth of required information is covered, test takers will not want to rely on this book alone.


Movement Disorder SocietyRecently, the American Academy of Neurology published an evidence-based guideline for the pharmacological treatment of chorea in Huntington’s disease. Although the progress in medical care because of the implementation of criteria of evidence-based medicine is undisputed, the guideline classifies the level of evidence for drugs to reduce chorea based on anchors in the Unified Huntington’s Disease Rating Scale-Total Motor Score chorea sum score, which were chosen arbitrarily and do not reflect validated or generally accepted levels of clinical relevance. Thus, the guideline faces several serious limitations and delivers clinical recommendations that do not represent current clinical practice; these are reviewed in detail, and arguments are presented why these recommendations should not be followed. To remedy the lack of evidence-based recommendations and provide guidance to a pragmatic symptomatic therapy of chorea in HD, a flow-chart pathway that follows currently established clinical standards based on expert opinion is presented. © 2013  Recently, the American Academy of Neurology (AAN) published an evidence-based guideline for the pharmacological treatment of chorea in Huntington’s disease (HD).A fundamental problem of the guideline is the assignment of “levels of importance” for different amplitudes of change in the UHDRS-TMS chorea sum score. These levels are used as anchors in the analysis, which classifies responses to therapy on which clinical recommendations in this guideline are based. A “2 to < 3-point” decrease in the UHDRS-TMS chorea sum score is classified as “moderately important,” whereas a “>3-point” decrease is considered “very important.” These cutoffs are arbitrarily chosen and do not reflect validated or generally accepted levels of clinical relevance for a change in the UHDRS-TMS chorea sum score. Seven subitems of different body regions contribute to the UHDRS-TMS chorea sum score. Thus, a mean improvement of just 1 point in less than 50% of the areas assessed could result in a “very important” change. Considering that chorea may not be the most relevant symptom of HD and that patients often do not seem to suffer from it,Several specific recommendations for the use of drugs in treating chorea were given, which need a critical comment—these are presented in the “Caveat” sections below. In addition, a pragmatic approach to treating chorea in patients with HD, based on expert opinion, is presented in the form of a stepwise decision tree outlined in a flow chart .The recommendation to use riluzole to treat chorea, which is referred to even in the abstract of the guideline, is not clinically established.4The uncritical use of tetrabenazine in doses of “up to 100 mg/day,” as recommended in the guideline, also is not clinically established practice.8In addition, the use of amantadine 300–400 mg/day), which is recommended in the first sentence of the guideline’s recommendation section right after tetrabenazine and before riluzole, requires a comment. The use of amantadine to treat chorea is highly controversial among experts, as recently revealed by a questionnaire obtained from HD experts: clinicians who had used amantadine described its benefit as small and transient; a minority considered it useful as monotherapy or adjunctive therapy, whereas a smaller but not insignificant number of respondents considered its use inappropriate for the treatment of chorea, and several cited inexperience with its use.00 mg/dayIn conclusion, the guideline in its current form may be misleading and does not provide reference to treatment recommendations by experts or to standards established in common clinical practice.In part, this may be due to the fact that, in the process applied during the development of this AAN guideline, results of secondary endpoints from randomized clinical trials primarily designed to answer other questions were included. Although this may be useful for scientific discussion, clinical conclusions from these results may be biased and should not be directly translated into clinical guidelines. Accordingly, a recent Cochrane review applying criteria of evidence-based medicine concluded that no statement can be made regarding the best medical practice for the control of motor and nonmotor symptoms in HD.11In this context, it should be considered that treatment recommendations in diseases with lower prevalence often lack the necessary clinical trials to document effects of clinically well-established therapies, as required by current evidence-based medicine criteria. Thus, expert opinions may be preferable to obtain meaningful guidelines.Yet how can meaningful, less disputed recommendations be established and provide a readily accessible reference for clinical practice? Recently, a pragmatic pathway for treating chorea in HD was developed based on a questionnaire that was presented to 52 HD experts mainly from North America and Europe, as mentioned above.This pathway will lead to satisfactory alleviation for most patients with clinically disturbing chorea who require treatment. It is important to bear in mind that treatment of chorea should aim to reduce involuntary movements, not to abolish them. Side effects, such as sedation and a negative impact on cognitive functioning, should always be assessed for and carefully monitored. Patients who respond inadequately to the suggested interventions should be referred to HD specialists. Currently, effective treatment of chorea should follow expert advice and not evidence-based guidelines in order to avoid side effects and potential harm to patients.Dr. Reilmann has provided consulting services, advisory board functions, clinical trial services, quantitative motor analyses, and/or lectures for Novartis, Teva, Siena Bitoech, Neurosearch Inc., Medivation/Pfizer, Lundbeck, Ipsen, Wyeth, ISIS Pharma, Link Medicine, Prana Biotechnology, the Cure Huntington’s Disease Initiative Foundation USA, MEDA, Temmler Pharma, and AOP Orphan Pharmaceuticals AG. He serves on the Advisory Board of the “Jacques and Gloria Gossweiler Foundation,” he has several responsibilities in the European Huntington’s Disease Network . and he serves as Global Coordinating Principle Investigator of clinical trials. Dr. Reilmann has received grant support from the High-Q-Foundation, the Cure Huntington’s Disease Initiative Foundation (CHDI), the Deutsche Forschungsgemeinschaft (DFG), and the European Huntington’s Disease Network (EHDN).


Experiments play a central role in science. The role of experimentsin computing is, however, unclear. Questions about the relevance of experiments in computing attracted little attention until the 1980s. As thediscipline then saw a push towards experimental computer science, a variety of technically, theoretically, and empirically oriented views on experiments emerged. As a consequence of those debates, today's computingfields use experiments and experiment terminology in a variety of ways. This paper analyzes experimentation debates in computing. It presentsfive ways in which debaters have conceptualized experiments in computing: feasibility experiment, trial experiment, field experiment, comparisonexperiment, and controlled experiment. This paper has three aims: toclarify experiment terminology in computing; to contribute to disciplinaryself-understanding of computing; and, due to computing's centrality inother fields, to promote understanding of experiments in modern sciencein general. After the birth of the stored-program paradigm in the mid-1940s, computing as a discipline started to form up. The first step in the discipline creation was to separate it from the fields that gave birth to it, especially from mathematics and electrical engineering. In the 1960s and the 1970s the field was divided over a debate concerning the mathematical nature of computing , they rhe 1980s –41.actually used and not of how it should be used. For instance, in the engineering tradition experimentation terminology is used much more loosely than in the tradition of experiment-based science. In short, the paper seeks an answer to the question, “What do computer scientists mean when they talk about experiments in computer science?”The view that computing is an inseparable combination of three very different intellectual traditions—theory, engineering, and empirical science —complicaempirical and experimental are not always used coherently. In sciences in general, it is relatively common to see the term “empirical” used to refer to research that relies on observation-based collection of primary data. The term “empirical research” stands in contrast with theoretical and analytical research. In many fields of science the term “experimental” goes deeper than “empirical” and refers to a specific kind of research, where controlled experiments are used for testing hypotheses. However, in the field of computing the term “experimental” has been used in a much more wider range of meanings.Among researchers in computing disciplines there is wide support for views of computing as an empirical or experimental science. However, the terms The role of experimentation in computing became a hot topic when Feldman and Sutherland  publisheThe “rejuvenating” report marked a shift of focus in methodology debates from the roles of theory and subject matter to the amount and methodological quality of empirical work in computing. The following decades saw numerous descriptive and normative arguments on the role of empirical and experimental research in computing. While some described how computer scientists actually work, others prescribed how they should work. Several studies compared research reports in computing with those in other fields—usually natural sciences or established branches of engineering , 45. In Over the course of time, many authority figures in computing advised computer scientists to experiment more , 47. Givempirical work. Computing and empirical research have been coupled in the literature in various ways, of which one particular perspective is discussed below. Computing and computers are, for one thing, subjects of research. Second, they are instruments of research. Third, they may be both at once.All the different accounts of experiments in computing—from controlled experiments to experimental algorithmics—fall into the broader category of subject of research . There research instruments in other fields. The history of computing and computers as instruments for experiments (simulations) in other fields is a long-established one. In his introduction to the famous 1946 Moore School lectures, Stibitz ).enning's . It is nwhy computer scientists should aspire to work like scientists or engineers in other fields do. One might justly ask, “If the subject matter of computer science is different from the other sciences, on what grounds should its methods be the same?” Computing is a unique field that introduces an array of novel techniques, so perhaps some room should be left for uniqueness in methodological sense, too.One could add a fifth objection related to the normative claims that advocates of experimentation sometimes made. Many of those authors who urged computer scientists to experiment more failed to justify In addition to the objections, Gustedt et al.  proposedDiscussions about experimental computer science, as presented in the section above, are complicated by the various uses of the terms “to experiment” (the verb), “an experiment” (the noun), “experimentation” (the noun), “experimental” (the adjective), and the myriad derivatives of those words. The confusion was visible already in the “rejuvenating” report, and, while a lot of effort has been spent on clarifying the concepts e.g., , 45, 98), 9845, 9t can be automated efficiently, reliably, feasibly, cost-efficiently, or by meeting some other simple criterion. A demonstration of experimental  technology shows that it can indeed be done. Including the terms “demonstration” and “experimental” in the same sentence may sound like a forced marriage of two incompatible concepts, but in the computing literature “experiment” is indeed sometimes used nearly synonymously with “demonstration,” “proof of concept,” or “feasibility proof” as the following examples demonstrate.The first and loosest use of the term “experiment” can be found in many texts that report and describe new techniques and tools. Typically, in those texts, it is not known if task experiments largely establishing the feasibility of new systems.” Plaice [ACM Computing Surveys, that the development of large software systems exemplifies experimentation in computer science—“and experimentation is the correct word, because we often have no idea what these tools will offer until they are actually used.” He continued to describe that what constitutes an experiment is that a scientist “carefully defines what must be done and then carefully sets out to do it.” Feitelson [Hartmanis and Lin [” Plaice  wrote, ieitelson  identifieitelson .ACM FCRC Workshop on Experimental Computer Science ) involved “experimental engineering” that produces new “techniques, insights, and understanding that come from building and using computer systems.” Hartmanis [experimentation generally means the ability to build a tool or system—more an existence proof than experiment.”The artmanis , though,artmanis , too, crtrial experiment evaluates various aspects of the system using some predefined set of variables. Typically, in those studies, it is not known how well a new system s meets its specifications or how well it performs. A trial  is designed to evaluate  the qualities of the system s. Those tests are often laboratory based but can also be conducted in the actual context of use with various limitations.The second use of the term “experiment” in computing goes further than demonstrations of feasibility. The in situ experiments, emulation, benchmarking, and simulation), the ones that permit the most abstraction—emulation, simulation, and benchmarking—fall into the trial experiment category. Emulation runs a real application in a model environment, simulation runs a model  application in a model environment, and benchmarking evaluates a model application in a real environment [Of Gustedt et al.'s  four-wayironment . Similarironment .not only the construction of new kinds of computers and software systems, but also the measurement and testing” of those systems. Furthermore, trial experiments are not a privilege of the applied side of computing. Glass [resort to trial runs because the problem is mathematically intractable.” Many types of validation of computational models of phenomena fall under trial experiments.McCracken et al.  wrote thg. Glass  proposedg. Glass  wrote thfield experiment takes the system out of the laboratory. Typically, in those studies, it is not known how well a system fulfills its intended purpose and requirements in its sociotechnical context of use. The system is tested in a live environment and measured for things such as performance, usability attributes, or robustness. The term “field experiment” is used in, for instance, information systems [in situ experiments”: real applications executed at the real scale using real hardware.A third common use of the term “experiment” is similar to trial experiments in that it is also concerned with evaluating a system's performance against some set of measures. However, the  systems , while G systems  used theexperimentation under real-world conditions” [The experimental computer science debates involve various examples of field experiments. A robot car race is an oft-used example of a field experiment, or “ditions” . In the ditions” .A outperforms system B with data set d and parameters p. An experiment is set up to measure and compare A and B, and the report shows that the new system beats its predecessors in terms of a set of criteria C. Johnson [A fourth common use of the term “experiment” refers to comparison between solutions. Many branches of computing research are concerned with looking for the “best” solution for a specific problem  or devel Johnson  called t Johnson  argued t Johnson , 47).B, d, C, or p favorably for his or her own system A. Zelkowitz and Wallace [All too often the experiment is a weak example favoring the proposed technology over alternatives.” There again, many fields of computing have introduced standard tests, input data, and expected outputs, against which competing solutions can be compared .controlled experiment. The controlled experiment is the gold standard of scientific research in many fields of science—especially when researchers aim at eliminating confounding causes—and it typically enables generalization and prediction. There are numerous uses for the controlled experiment setup; for instance, it is often used for situations where it is not known if two or more variables are associated, or if x causes y.A fifth common use of the term “experiment” refers to the In many arguments for experimental computer science, by “experiment” the author explicitly or implicitly means “controlled experiment” but not always for the same reasons. Peisert  advocateExperiments played a central part in the development of modern science, and over the centuries experiments also evolved. In modern science experiments play many roles; often in relation to theory but also independent of theory . In scieThe spectrum of experiments is fully visible in computing fields. The breakthroughs in computing happened at a junction of various fields, such as mathematical logic, electrical engineering, and materials science. Since the birth of the stored-program paradigm, computing has adopted methods from an even broader variety of fields. As the disciplines that gave birth to computing each have reserved a very different role for experiments, it is unsurprising that the computing literature uses experimentation terminology in a variety of ways. Sometimes the term refers to empirical research in general, sometimes to evaluation strategies, sometimes to proofs of concept, and sometimes to controlled experiments. The philosophy of experiment reveals some diversity of experimental terminology in fields other than computing, too.The role of experiments in computing disciplines has been highly debated since the “rejuvenating experimental computer science” report in 1979. A large number of viewpoints to experimental computer science have advocated a variety of views to experiments, each with their own aims, methods, and assumptions. Experiment terminology also played a key rhetorical role in debates about the future directions of computing as a discipline. As experiments are historically central to sciences, in visions of computing as a discipline it is less risky to adopt and redefine the term “experiment” than to ignore it. The ambiguity of methodology terminology in computing parallels the situation in the philosophy of science, where experiments remained an unopened black box until the 1980s .The disciplinary understanding of computing requires a naturalistic view into experiments in the field. There surely is a place for the many normative arguments on experiments in computing that have been structured around idealized views of science and the experiment. But there are also good reasons to challenge the idealized and received views of experiments. How scientists experiment has changed greatly since the days of Galileo and Bacon, as has the role of experiments in the philosophy of science. The form and function of experiments have never been rigid. The experiment has never been a mere judge between right and wrong theories. Experiment is a multidimensional phenomenon, and it is important that those dimensions are appropriately analyzed and discussed in computing, too. Also, insofar as experimentation language in computing needs clarification, it is of great help to understand the different ways in which experiments have been conceived in computing.Methodological surveys and meta-analyses of computing research have already revealed a great diversity of views concerning empirical methods in computing, as well as what is called “experiments” in computing. Many of those views are similar to the epistemological strategies of researchers identified in the philosophy of experiment , 82. AlsPerhaps the use of experimentation terminology in computing should be made stricter and brought in line with some strict definitions of experimental science. Or perhaps our terminology needs to reflect what is really going on in computing and other disciplines. Either way, it is a matter of disciplinary self-understanding to take computing seriously, in its own right, and to study the discipline of computing from a nonidealized, naturalistic viewpoint. This short survey presents five faces of experiments in computing—feasibility experiment, trial, field experiment, comparison, and controlled experiment. There is a lot more to experiments in computing than what meets the eye, and we believe that their study can benefit both computing as a discipline and our general understanding of experiments in science.


Major academic ophthalmology departments have been expanding by opening multi-office locations (“satellites”). This paper offers a first glimpse into satellites of academic ophthalmology departments.Leaders of seven medium to large, geographically diverse departments agreed to participate. One- to two-hour phone interviews were conducted to assess the features of their satellite practices.Success as clinical entities, profitability, and access to patients were stated goals for most satellites. In approximate descending order, refractive surgery, retina, oculoplastics, and pediatric ophthalmology were the most common subspecialties offered. Faculty staffing ranged from recruitment specifically for satellites to rotation of existing faculty. Except for a department with only one academic track, satellite doctors were a mix of tenure and mostly non-tenure track faculty. According to these department leaders, scholarly productivity of satellite faculty was similar to that of colleagues at the main campus, though research was more community-based and clinical in nature. Fellowship but little resident education occurred at satellites. Though it was agreed that satellite practices were integral to department finances, they accounted for a smaller percentage of revenues than of total departmental visits.Satellite offices have offered access to a better payor mix and have boosted the finances of academic ophthalmology departments. Challenges include maintaining collegiality with referring community physicians, integrating faculty despite geographic distance, preserving the department’s academic “brand name,” and ensuring consistent standards and operating procedures. Satellite clinics will likely help departments meet some of the challenges of health care reform. In recent years, major academic ophthalmology departments have been expanding by opening multi-office locations (“satellites”). To our knowledge, there is little peer-review literature on satellite offices in academic medical departments in general, ,2 let alOphthalmology departments were in expansion mode in the 1970s and 1980s. Under the auspices of a very young National Eye Institute, the first comprehensive assessment of major needs and opportunities in vision research in the United States was published . Many ey, Medical Education in the United States and Canada 2Locations ranged from within 5 minutes of the main campus to about 100 miles away for satellites of three departments. A leader who opened his department’s first satellite in the early 1990s, recalled, “We asked if the satellite would fulfill the missions of an academic institution—patient care, research, teaching. There was an element of opportunism. We asked was [our medical school] parent there with other departments? This provided access to patients. Were personnel there? [Aside from money], we needed space, referrers, and staff. When we got a marriage of two of three factors, it became a growing concern, an ‘entity’”.The number of satellites (range: 1–6) was not correlated with the total number of departmental clinical encounters or with the size of the surrounding metropolitan area. In fact, in this survey the departments with the fewest and most satellites were located in cities of similar population. Another department had twice as many satellites as a similar-sized department in a different city.Satellites of all 6 departments offered multiple subspecialties, but not the same ones at every satellite. Satellites of two academic centers did not offer comprehensive ophthalmology to preserve the referral base of comprehensive ophthalmologists; some of their satellites offered only retina. The most common subspecialties at satellites were (in descending order) refractive surgery and retina (close approximation), oculoplastics and pediatric ophthalmology, and cornea and glaucoma.Most satellite clinics were staffed by junior faculty with a few senior level faculty. However, one leader explained that satellites were staffed by senior level faculty in order to “ease the strain with the community.” In another department, the profile has changed; all faculty at its first satellite were senior level, but over time satellites have become staffed by junior faculty. Two chairpersons were seeing patients at satellites.One department had a single academic track; the rest had multiple tracks, the main ones being “traditional”/”tenure” track  and the “clinical care”/”clinician educator” track. Regarding recruitment, “most faculty [at satellites and at the main hospital] are hired as clinician educators unless they are fully bred as a clinician scientist with lab interest,” explained one representative.In a department with close to 10 satellites, tenure-track faculty had a high representation at satellites closer to the main campus, whereas clinician-educators populated outlying satellites. Except for the department with one satellite, each satellite had a medical director, usually a clinician educator. One leader stipulated when opening his first satellite 20 years ago, the medical director “had to maintain patient volume and command respect from referring doctors. Our doctor could not be inferior to referring doctors and had to be better than the local practitioner”.Faculty staffing could involve recruiting specifically for a satellite, assigning current faculty or having them volunteer to go. One representative stated, “There is a better payor mix at satellites, so you want faculty who will work hard and be willing to compete against good people in the community. We don’t want doctors to view joining a satellite as a way to get into [our department]”. Another department leader declared, “We don’t hire specifically for a site. We are part of a team. We accommodate the needs of the whole institution. Faculty have a vested interest in the well-being of the eye institute and buy into the idea of its success. We want to create ownership”.Trainee education occurred at some or all satellites, but fellows were present more so than residents. There was no “resident clinic” at any satellite anywhere. Only one chair stressed his expectation of teaching: “Faculty who are full-time at satellites still have to go to the main hospital to teach”. Another leader admitted that teaching at a satellite could impede its efficiency and presumably its attractiveness to patients. Summarized one chair: “Eventually a satellite has to fulfill the academic mission, but in order for the satellite to survive, it has to be noted for providing good patient care”.As a share of total revenue generated by the respective department of ophthalmology, satellites accounted for a range between 10% (program with only one satellite) to 50% (program with the most satellites)  keep satellite doctors involved,” said one representative. A related issue (but mentioned by only one representative) was how to preserve the “[academic] brand” and not dilute it when opening remote satellite clinics.Competition with community (referring) ophthalmologists posed another challenge. Only one leader said there was not much antagonism—at least none of which he was aware. “The scope is so limited; we are not offering all specialties”. However, most representatives were aware of antagonism from community ophthalmologists at the start, evolving into wariness as satellites grew in number. “We discovered that local eye doctors voted 100 to 1 against our presence,” recalled a representative whose first satellite opened 20 years ago; all faculty were required to go. “At the time, there were no comprehensive ophthalmologists on faculty. Our goal, therefore, was to be a consultation service to the community, not to be in the hospital and not to do surgery,” he continued. In response to community antagonism, another department communicated that it was placing only specialists in its satellites. “However, if a patient comes to us with a cataract, we are not going to avoid doing the surgery,” the department leader said. Two departments gave community ophthalmologists the option to buy into satellite practices or use a satellite surgery center. Another leader explained that the department told community doctors that satellites were part of the dean’s initiative, not the doing of the department itself.Five departments were building more satellites at time of writing—all outside the geographical center, with one being built 50 miles away from the main campus. The representative of the sixth program  was unsure about expansion: “We have to think carefully. There is potential risk with any growth, especially in this uncertain time with health care reform. Every satellite represents a financial risk as it entails financial investment. When you open a satellite, you look for confirmation that what you did was good”. This leader, however, admitted, “I believe that we would have enjoyed greater success had we opened the satellite sooner”.Similarities and differences amongst the programs are summarized in Table To our knowledge there is no literature on satellite offices in academic ophthalmology. Satellite offices have offered access to a better pay or mix and have boosted the finances of academic ophthalmology departments. In fact, the decision to build or continue a satellite practice appears to be nearly entirely financial, distinguishing it from a department’s other divisions. The fact that satellites do not offer all sub-specialties may lower overhead and lead to more referrals to the main campus. Areas to be addressed include trainee education at satellites; integration and mentorship of satellite faculty; relationship with community physicians;  and presUnderstandably, the triad of patient care, teaching, and research forms the mission of all academic medical institutions. Direct patient care, however, is not conducted in basic science laboratories. Moreover, limited research is conducted in most resident clinics, which, being centerpieces of education, usually are not held to the same financial standards as other divisions. Therefore, it may not be valid to hold satellites to the standards of the over all department as one criticism has been that they do not contribute to the education mission.The financial contribution of satellites most likely supports this mission as well as others of the department and medical school. More than 100 years ago, however, Flexner opposed this model of full-time faculty for fear that medical education would suffer when faculty were pressured to engage in clinical practice to support the institution and became the “scientifically dead practitioner” ,9. This Issues of faculty integration, academic progress of satellite doctors, and “brand” preservation, , would be worth further investigation as they pertain to academic identitity. Although representatives asserted that satellite faculty were engaged in research, publications, and teaching, the retention rate of satellite faculty (many of whom are junior level clinician-educators), their rate of promotion, and time to promotion were outside the scope of this study. These rates could be lower if mentorship and interaction with fellow faculty are lacking; compared with other tracks, clinician educators at one major institution were of lower rank and were less satisfied with progress toward academic promotion.  ConcernsData saturation was achieved for the survey questions. Some differences that were uncovered were number of satellites relative to department size, academic track and rank of satellite doctors, and decision to offer comprehensive ophthalmology. The number of satellites of a given department may reflect local conditions like regional competition and presence of managed care. Revenue per visit at satellites was usually less than for the over all department, perhaps reflecting lower complexity visits and/or lower reimbursement for the same in-hospital procedures. However, some aspects of overhead, like staff/patient ratio, may be lower at satellites.Growth of satellite practices may help academic departments shoulder financial risk better than can a solo practitioner or a small group practice when participating in the Medicare Shared Savings Program vis a vis Accountable Care Organizations (ACOs). Since specialists will have to work closely with primary care providers to obtain patient referrals and to receive larger shares of cost savings, some believe that ACOs will allow large groups to be better positioned to participate in the savings program . Until tnew patient visits), this pilot study may lead to a larger, more comprehensive and systematic study of ophthalmology clinical practice and organizational behavior. Such study would benefit from a representative sample of staff and faculty members, not just department leaders.Satellites appear to deliver on one aspect of the tripartite mission—patient care. Aided by payor mix, high-revenue subspecialties, and increased efficiency, they contribute to department revenues. Examining issues raised by this study may help departments ensure they are meeting their mission in a balanced fashion and help ensure satellite and department success. Because satellites can account for a large proportion of a department’s total patient encounters (and even larger proportion of its The author has no competing interest.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/13/79/prepub