Artículo viernes 3 abril

Lawitz E, Mangia A, Wyles D, et al. Sofosbuvir for Previously Untreated Chronic Hepatitis C Infection; N Engl J Med. 2013 Apr 23.

Sesión IAM

La sesión de mañana es de carácter obligatorio para todos, salvo los que tengan guardia, se pasará lista
Saludos

Algoritmos de DM2

Saludos compañeros les dejo un algoritmo nuevo de la Asociación Americana de Endocrinólogos Clínicos, esta interesante ojalá lo puedan revisar. Esta en dropbox/sesionesbibliograficas/artículos/endocrino/DM2

Jesús

Patología

Ya se encuentra en el dropbox el resumen de la sesión de patología del 30 de abril.

clase de cardio

les recuerdo mañana toca clase de cardiologia, lean la guia de sincope que subi en la seccion de sesionesbibliograficas/clases/cardio

Articulo

Les subo mi articulo del viernes al dropbox, saludos

Sesión Bibliográfica viernes 19 abril 2013

Ya está en el dropbox el artículo que elegí para la sesión bibliográfica del 19 de abril, se los dejo con anticipación para que lo puedan leer. 

Histopathologic Characteristics of Atherosclerotic Coronary Disease and Implications of the Findings for the Invasive and Noninvasive Detection of Vulnerable Plaques.
JACC 2013: 61(10); 1041-51 

Sesión Interinstitucional

Hola compañeros!

El próximo jueves 18 de abril será la sesión interinstitucional en el hospital Xoco, en esta ocasión me toca a mi ser la representante de nuestra sede, por lo anterior les pido que revisen el caso y nos reuniremos el lunes 15 de abril para aportar ideas sobre el abordaje y los probables diagnósticos.

El resumen del caso lo subiré al dropbox en la carpeta de sesiones interinstitucionales...

Saludos!!

sesion bibliografica

el dia de mañana mi articulo es Combination Antifungal Therapy
for Cryptococcal Meningitis N Engl J Med 2013;368:1291-302. lo subire al dropbox

clase de nutricion

ya se subio la clase de nutricion al dropbox, recuerden subir todas las clases al dropbox con una notificacion previa por este medio o via twitter o facebook.

Penfigo

Les subo dos artículos de penfigo, uno las guías británicas y otro de penfigos paraneoplasicos. Espero les sirva. Carpeta de articulos, dermatologia, penfigo.

A propósito de la sesión radiopatológica de hoy...

Are You a Great Diagnostician?
Batya Swift Yasgur, MA, LMSW Mar 27, 2013

Introduction
A majority of doctors think they have it; very few will say that they don't have it. And many are happy that they're "good enough."

The epithet is "great diagnostician." It's the doctor who, when confronted with a patient whose condition doesn't seem to have an obvious diagnosis, suspects what the disease or ailment might be or can point testing in the right direction. Or who recognizes potential signs of an uncommon disease that many doctors have never seen and don't think of. It's the doctor who simultaneously thinks of both horses and zebras.

"Great diagnosticians recognize that even the 'simplest' cases might turn out to be complex, and that sometimes the most 'complex' presentations might have a simple explanation," says Alan Katz, MD, Cardiologist, Cardiac Imaging Department, St. Francis Hospital, Roslyn, New York, and Vice President of Medical Informatics at 
Catholic Health Services of Long Island. The trick is to "bring experience and freshness to every case, and avoid thinking in black and white."

Every Doctor Is Not Equal

Are there really categories of good, better, and best diagnostician? And how important is it to be in "the best" category?

It's critically important, according to patients as well as physicians. Patients, of course, want to be rid of what ails them and are waiting for the physician to ferret out clues and pull the correct diagnosis out of a hat with a triumphant flourish, bringing clarity and solutions to troublesome or dangerous health problems.

But for doctors, finding a difficult condition is rarely an epiphany in which the answer shoots up in a burst of fireworks. It's a combination of many things, including a solid knowledge base, good listening skills, ordering the right tests and interpreting them correctly, performing a skillful examination, and -- perhaps most important -- thinking creatively.

Some of today's physicians are falling short in these qualities, according to a just-published medical record review of 212,165 patient visits at 2 major primary care facilities.[1]

The researchers found 190 cases of diagnostic errors that "had potential for moderate to severe harm." Worse, these diseases were not exotic "zebras," but instead were run-of-the-mill "horses," such as pneumonia, congestive heart failure, acute renal failure, primary cancer, and urinary tract infection. The researchers attributed most errors to "patient-practitioner clinical encounter-related processes, such as taking medical histories, performing physical examinations, and ordering tests."

This leaves both patients and physicians in trouble. Patient health is compromised. And physicians face potential legal complications, because failure to diagnose is one of the most common causes of medical malpractice lawsuits.

Beyond avoiding litigation, being a good diagnostician has another advantage: It builds your practice. A good diagnostician's waiting room is crammed with patients who've been on the waiting list for weeks or even months but won't see anyone else. 

	An Art, a Science, a Way of Thinking, or a High IQ? Many factors go into being a good diagnostician. It's been suggested that IQ is a factor, or that you need a photographic memory of all the facts you've crammed into your brain from medical school. Or that you need to attend lots of medical meetings and burn the midnight oil reading the latest research findings. Certainly, a degree of learning and recalling some of the more esoteric symptoms of unique ailments can affect your ability to make a diagnosis. If you don't have the knowledge to start with, you can't call upon facts that you don't possess. But experts say there's more to it than that. New graduates leave medical school crammed with essential clinical information, says Kathryn Montgomery, PhD, Professor of Medicine and Professor of Medical Humanities and Bioethics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and author of How Doctors Think: Clinical Judgment and the Practice of Medicine (Oxford University Press, 2006). But that's only a fraction of what's needed to be a good diagnostician. "What's important is how doctors' minds work and how they put things together," Dr. Montgomery notes. Physicians have to start thinking about their thinking patterns, agrees Jerome Groopman, MD, Professor of Medicine at Harvard Medical School, Boston, Massachusetts, and author of a book also titled How Doctors Think (Houghton Mifflin, 2007). "There are several cognitive flaws in medicine that are so deeply ingrained, most physicians never critically examine their validity." For example, budding physicians are taught that hoofbeats almost invariably point to horses. "It's statistically true that there are more horses than zebras," comments Hillel Braude, MD, author of Intuition in Medicine: A Philosophical Defense of Clinical Reasoning (University of Chicago Press, 2012). "But there is always an interplay between them." Dr. Braude compares ignoring the "zebras" to looking for lost car keys under the lamppost because that's where the light is. "Assuming that something is a 'horse' shines the diagnostic light away from true 'zebras.'" Marianthe Grammas, MD, Clinical Fellow in Geriatric Medicine, Yale University School of Medicine, New Haven, Connecticut, adds, "There is always a differential diagnosis, even if the actual diagnosis seems straightforward. There are always at least 2 possibilities." However unlikely, one could be a zebra.
	What About Intuition? Intuition is frequently associated with the "art" rather than the "science" of medicine, notes Dr. Braude, and is perceived as biased or "fuzzy." But that doesn't invalidate the role of "tacit knowing" in the diagnostic process. Dr. Montgomery distinguishes between "thinking slow," which involves using logic and data, and "thinking fast," which is a reflexive process more akin to intuition. "There is a bidirectional relationship between these 2 forms of thinking when it comes to clinical diagnosis," Dr. Montgomery says. "The more knowledge and experience you have, the more fine-tuned your intuition will be. And the better your intuition, the more you'll know when and where to look for further information -- studies, guidelines, conferences, or collegial consultations." Allan Katz, MD, gives an example of an intuitive hunch. "I checked up on a patient who'd just had bypass surgery and I noticed a rash on her neck. I referred her to a dermatologist, who was unconcerned. But some nagging feeling led me to refer the patient to a dermatologist at a cancer center, where she was diagnosed with lymphoma." Still, intuition alone is not enough, says Kelli Harding, MD, Assistant Professor of Clinical Psychiatry, Columbia University Medical Center, New York, New York. "We owe it to our patients to incorporate validated measurement instruments into diagnosing psychiatric patients, rather than relying on potentially imprecise clinical impressions. Guidelines and algorithms lend objectivity and can be helpful road maps." Consensus guidelines and algorithms have to be used carefully, Dr. Groopman cautions. He expresses concern that today's physicians are overreliant on evidence-based medicine. "While findings of controlled trials are valuable, they frequently don't translate into real-world practice, as applies to an individual patient," he comments. He warns against rigidly applying consensus guidelines and clinical algorithms. "The temptation for time-pressured physicians is to seize upon the first bit of information the patient offers, plug it into an algorithm, and become anchored to single linear path rather than thinking independently and creatively." But it doesn't have to be an either/or proposition. "Using measurement tools doesn't mean have to mean that doctor/patient interactions will become robotic, or that we'll stop using clinical judgment," Dr. Harding says. These guidelines are "mere basics that assure a minimally competent diagnosis," adds Dr. Montgomery. "They are at the bottom of the ladder and must be incorporated into a much broader diagnostic framework." Testing, 1, 2, 3 Although tests are extremely important, they should be used along with critical thinking -- not in place of it, say experts. They should be used judiciously and never as a substitute for a thorough history and physical examination, Dr. Katz advises. "Whenever you order a test, ask yourself, 'What's my differential diagnosis? How will I act differently based on the results?'" He suggests ordering tests in "reasonable sequence" rather than "all up front," not only to contain costs but also to look at findings in a stepwise fashion. This increases the likelihood that important data won't be overlooked. Experts regard "active listening" as the most critical component of successful diagnosis. Lesley Ann Fein, MD, MPH, a rheumatologist and infectious disease specialist in West Caldwell, New Jersey, often sees patients with complicated conditions, who have been to previous physicians without obtaining a satisfactory diagnosis. "Patients need to tell their story all the way from the beginning. I allow open-ended narration and also engage in pointed questioning. I ask myself, what variables might be linked? What doesn't belong? I follow the leads while my mind is simultaneously going through the differential diagnosis, narrowing it down. The answer may lie deep in their medical history, in the remote past, in some 'trivial' detail no one ever questioned before," says Dr. Fein. Listening and Looking for Subtleties Dr. Fein acknowledges that the history she takes is time-consuming, with appointments lasting a minimum of 3 hours. "I don't participate with insurance plans because I don't want the time constraints," she says. Dr. Fein adds that she asks patients to bring all their diagnostic tests, no matter how old. "The most ancient test might contain the most important information," she says. But even in time-pressured settings, "you can listen for clues," says Dr. Groopman. "Attune your ear to nuances, and deviations from the typical presentation will jump out at you." Daniel Pranson, MD, a pediatrician in Chicago with a reputation as a top-notch diagnostician, described an instance of finding the less obvious diagnosis. A toddler presented with slight fever and rhinorrhea, and he suggested a decongestant. Two days later, the mother returned saying, "He's not acting like himself." Dr. Pranson accurately suspected meningitis. What made Dr. Pranson jump to the zebra instead of the horse? "I'm no genius, and I wasn't the class valedictorian," says Dr. Pranson. "I try to stay current with the literature, but more important, I look at subtleties. And I regard a mother's return visit as a red flag, which I trust. Parents can sense when something isn't right with their child. This motivated me to look more carefully under the surface presentation." Conclusion Even the best doctor and diagnostician will make a mistake or miss something on occasion. "The real issue is whether you've learned from your mistakes -- and from the mistakes of your colleagues," Dr. Groopman says. He adds that integrating a strong knowledge base with regular examination of your thinking patterns will enable you to continue honing your diagnostic skills. References 1. Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013 Feb 25. [Epub ahead of print] Medscape Business of Medicine © 2013 WebMD, LLC Cite this article: Are You a Great Diagnostician? Medscape. Mar 27, 2013.