Diagnosis and Decision Making

posted 9 Dec 2012, 10:13 by NicolaAvery

via http://www.healthinformaticsforum.com/page/component-2-unit-4-lecture-c
Systematic (VINDICATE - organ system), Anatomic, Pathophysiologic (e.g. bilirubin metabolism), Pattern recognition (naturalistic decision making), Mnemonics, Heuristics, Mathematics (e.g. Baye's theorem), temporal patterns (acute, sub-acute)
VINDICATE = Vascular, Infectious, Neoplastic, Drugs, Inflammatory/Idiopathic, Congenital, Autoimmune, Endocrine/Metabolic
Organ - neuro, cardiovascular, pulmonary, renal, heme, GI, Bones, Joints, Skin
Patterns - occurrence and reoccurence of symptoms over a specified period, degeneration signals???
Heuristics - more likely to see uncommon case of common disease rather than uncommon disease - probabilities???
Maths - decision rules e.g. Wells criteria for pulmonary embolism, Centor criteria for strep throat

Being able to admit ignorance

posted 1 Jun 2012, 15:37 by NicolaAvery


Difficult for medical professionals to admit they don't know. Suggests that issue starts in medical school with many m/c assessment where there is always one correct answer and to expect one answer exists.

"It’s human nature to seek definitive answers, especially when dealing with one’s own health.  It’s not uncommon for me to see patients whose symptoms aren’t particularly bothersome but which have gone on long enough that anxious curiosity compels him or her to seek medical care.  When we get sick we want to know what the illness is, both for our peace of mind and in order to be able to explain ourselves to others

A good clinician declaring ignorance is really saying much more: I may not know what is causing your symptoms, but I’ve done a thorough investigation into your case and can conclusively say that you don’t have any of the truly dangerous medical problems that can produce symptoms similar to yours.  So while you may come away from our visit without a knowledge of what is causing your problems, at least you know what it isn’t, and you can rest assured that we have looked for—and excluded the possibility of—anything that puts your life or health at significant risk."

Science Based Medicine

posted 1 Jun 2012, 15:15 by NicolaAvery   [ updated 10 Jun 2012, 12:14 ]


"most recommendations of science-based medicine are not “truth” per se; they are simply the best recommendations physicians can currently make based on current scientific evidence. Be that as it may, the problem with the “truth wins” viewpoint is that the “truth” often runs into a buzz saw known as a phenomenon that philosophers call naive realism. This phenomenon, boiled down to its essence is the belief that whatever one believes, one believes it simply because it’s true. In the service of naive realism, we all construct mental models that help us make sense of the world.

There’s also another strategy that people use to dismiss science that doesn’t conform to their beliefs. I hadn’t thought of this one before, but it seems obvious in retrospect after I encountered a recent study that suggested it. That mechanism is to start to lose faith in science itself as a means of making sense of nature and the world. The study was by Geoffrey D. Munro of Towson University in Maryland and appeared in the Journal of Applied Social Psychology under the title of The Scientific Impotence Excuse: Discounting Belief-Threatening Scientific Abstracts. There were two main hypotheses and two studies included within this overall study.

Basically, the hypothesis was that encountering evidence that conflicts with one’s beliefs system would tend to make the subject move toward a belief that science can’t study the hypothesis under consideration, a hypothesis known as the “scientific impotence” hypothesis or method. In essence, science is dismissed as “impotent” to study the issue where belief conflicts with evidence, thus allowing a person to dismiss the science that would tend to refute a strongly held belief. The problem, of course, is that the major side effect of asserting scientific impotence discounting is that it leads a person to distrust all science in general, or at least far more science than the science opposing that person’s belief"


3 phases

"Patients routinely participated in large, multi-center prospective randomized trials to answer these questions. It was routine for them not to charged for participating in the trial — the drug(s) and additional testing would be funded by the company whose drug was being studied. Patients enrolled willingly, eager to help advance science and perhaps, in some small way, their fellow man. It never dawned on me in those early days why hospitals and research centers were so eager to promote research.

Naturally, there was a desire for research centers to recruit more and more trials to grow their prestige in the community. Small companies would use research protocols to gain marketshare in competetive hospital accounts using, in part, this patient-subsidized budget strategy. Worse, they would create new add-on trials only marginally relevant for the same growth strategy even after devices were FDA-approved.

With the growing cost of healthcare being offloaded by insurers on the backs of patients, patients have seen their insurance deductibles rise. Employers are finding they can no longer provide “Cadillac plans” to their employees due to costs, and instead move to insurance programs that are less encompassing in an effort to control costs to their employees. As a result, some patients even have “lifetime caps” limits on their insurance. Consequently, patients have become keenly aware of the costs of providing their healthcare. I have noticed that patients are increasingly reluctant to participate in clinical research. Perhaps this is because they understand the relationship between ANY healthcare and THEIR expenses."

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