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Narrative as Rhetoric and the Art of Medicine
Published in James Phelan, Narrative Medicine, 2023
Rowland’s story does not make such thematizing moves but, given its occasion and purpose, a rhetorical analysis of it would. Differential diagnosis is one way of thematizing an individual patient. Nevertheless, consistent with the principle that Rowland owns the story of his illness, the rhetorical analyst would not want to replace the mimetic with the thematic, but instead retain an awareness of Rowland’s individuality and the particular details of his situation. In so doing, a rhetorical analyst would consider elements of his story that fall out of the clinician’s account, especially elements that are only tangential to the report of symptoms. The most salient of these are occasion and time. The rhetorical analyst would home in on what it means for Rowland to be telling this story this way on this visit, and ask how it relates to previous storytelling on previous visits. With time, the rhetorical analyst would attend to Rowland’s downplaying of his stress at work and think about it in a way that Rowland does not. Where Rowland fails to see a connection to his chest pains, the rhetorically oriented caregiver would note the duration of the stress—its persistence over time—and consider the hypothesis that it is a contributing factor to his chest pains. As a result, the treatment plan would involve some discussion about possible ways to reduce that stress.
The Human Aspects of Medicine
Published in John S. Axford, Chris A. O'Callaghan, Medicine for Finals and Beyond, 2023
Chris O'Callaghan, Alison Maycock
Clinicians make sense of the information they gather by a process of clinical reasoning, which aims at making a working or differential diagnosis and management plan. Clinical reasoning has several stages which may be reiterated until a best course of action is identified. We have already identified some of the key components of this and a framework for understanding clinical reasoning is summarized in Figure 1.4.
Tips for the Clinician Educator
Published in Larrie Greenberg, A Primer for the Clinician Educator, 2022
I don’t believe in so-called defensive medicine and have never practiced that way. In my almost 50 years of practice seeing tens of thousands of patients, I have been fortunate to have never been sued despite caring for very ill and complex patients, some of whom had poor outcomes. There is so much technology in medicine today, and it is so easy to depend on that to diagnose and treat patients. I believe in the tradition in getting trainees to focus on obtaining a great history and doing a thorough physical exam before entertaining any laboratory tests or imaging studies. On rounds, I often hear trainees rushing through the history and physical, and then moving right into the lab studies without hearing anything about their differential diagnosis and what they feel are the most likely diagnoses. How does one know what laboratory or imaging studies to order if the differential diagnosis is not clear? When one orders a complete blood count, based on the most likely diagnosis, what would one expect the count to show? There shouldn’t be many surprises from laboratory study results when we deal with patients.
Neuro-Ophthalmic Literature Review
Published in Neuro-Ophthalmology, 2022
David A. Bellows, John J. Chen, Hui-Chen Cheng, Panitha Jindahra, Peter W. MacIntosh, Collin McClelland, Michael S. Vaphiades, Xiaojun Zhang
Patients with visual snow (VS) symptoms present to neuro-ophthalmology clinics with increasing frequency. The differential diagnosis is large, and it remains unclear as to whether these patients need diagnostic testing beyond what is accomplished in the clinic. Two experts debate this topic and try to answer the question of “to what extent should VS and visual snow syndrome (VSS) be evaluated in the clinic?” By definition, VS is the primary symptom of idiopathic VSS. Patients with VS may have primary (idiopathic) or secondary VSS. As with other idiopathic conditions (e.g., idiopathic intracranial hypertension), the symptoms should be consistent with typical VS, the ocular examination should not have any other findings to better explain VS, and there should not be other signs or symptoms other than VS that might suggest an alternative ocular or systemic disorder before making the diagnosis of primary VSS. The decision for the need of additional “out of clinic” testing for VS (including neuro-imaging and electrophysiology) should be driven by the presence or absence of these other historical and examination findings. Thus, the answer is nuanced, and the diagnosis should be made on a case-by-case basis. My opinion is that, if the VSS originated at an early age, is non-progressive, is typical in historical presentation, and the patient has a normal neuro-ophthalmological examination, including automated perimetry and macular spectral domain optical coherence tomography, then ancillary testing is generally unnecessary.
Types of clinical reasoning in a summative clerkship oral examination
Published in Medical Teacher, 2022
Vamana Rajeswaran, Luke Devine, Edmund Lorens, Sumitra Robertson, Ella Huszti, Daniel M. Panisko
Three investigators (VR, LD, and DP) independently classified the scripted reasoning questions of the SCOE’s clinical reasoning stations as ‘Type 1 clinical reasoning,’ ‘Type 2 clinical reasoning,’ or ‘not classifiable,’ according to the type of clinical reasoning that would typically be invoked to respond to the question (Figure 2). An inter-rater reliability kappa was calculated for the classifications. Where there was a lack of agreement, the question was discussed, and classification consensus was reached. Type 1 clinical reasoning involved pattern recognition and first impressions. For example, questions asking for initial diagnosis or for the first management priorities were classified as Type 1. Type 2 clinical reasoning questions involved the use of an analytic approach that asked for the examinee’s thorough differential diagnoses or for complete management of the case. The assessment of clinical reasoning in this study focused on hypothesis generation, problem representation, differential diagnosis, leading or working diagnosis, diagnostic justification, and management (Daniel et al. 2019). The remaining ‘not classifiable’ questions did not require clinical reasoning, offered limited opportunity for information gathering, queried content knowledge, or required some extent of Type 1 and Type 2 clinical reasoning simultaneously.
The use of EPA assessments in decision-making: Do supervision ratings correlate with other measures of clinical performance?
Published in Medical Teacher, 2021
Victor Soukoulis, James Martindale, Megan J. Bray, Elizabeth Bradley, Maryellen E. Gusic
Scores for the patient encounter domain of the CPX incorporate the percent of items on the physical exam checklist completed by the standardized patients that are marked as having been performed during the encounter (‘done’) plus the percent of items documented (‘present’) in the history, physical exam, differential diagnosis and evaluation plan sections of the post-encounter note scored by faculty members of the OSCE Committee. In the differential diagnosis section, diagnoses must be prioritized and justified using facts from the history and physical exam. Faculty scorers use a specific rubric to score the post-encounter note for each station. The overall domain score reflects performance of history-taking, physical exam, and clinical reasoning skills on all 10 stations of the exam. Clinical reasoning scores are calculated using scores from the differential diagnoses section of the note plus the scores related to the creation of appropriate diagnostic plans.