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Psychiatric Diagnosis And “Early Closure”


Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry. The author writes:

Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: My tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule).

At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: What else could this be? Read more »

*This blog post was originally published at Shrink Rap*

Stick To One ER, Avoid Unnecessary Tests

Via Kaiser Health News:

On a recent Friday night at the Boston Children’s Hospital ER, Dr. Fabienne Bourgeois was having difficulty treating a 17-year-old boy with a heart problem. The teen had transferred in  from another hospital, where he had already had an initial work-up — including a chest X-ray and an EKG to check the heart’s electrical activity. But by the time he reached pediatrician Bourgeois, she had no access to those records so she gave him another EKG and chest X-ray. He was on multiple medications, and gave her a list of them. But his list differed from the one his mother gave doctors, neither of which matched the list his previous hospital had sent along.

This is excellent advice. Every ED has seen a patient, probably today, with “they saw me at the ER across town, but they didn’t do anything and I’m still sick.” While it makes some sense not to return to a restaurant that gave you a meal that wasn’t to your tastes, medicine is quite different.

If a patient gives me this history, I now have a blank slate, and need to essentially start at zero with them. So, I will do the correct workup to exclude the life threats based on the history and physical exam, which may be exactly the tests they had yesterday. I’m not going to assume they did the same tests, or that they were normal. It’s the standard of care at this time, and I have very, very few alternatives. Read more »

*This blog post was originally published at GruntDoc*

The Business Of Anticoagulation

This is a guest post by Dr. Juliet Mavromatis:

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The emergence of a new generation of anticoagulants, including the direct thrombin inhibitor, dabigatran and the factor Xa inhibitor, rivaroxaban, has the potential to significantly change the business of thinning blood in the United States. For years warfarin has been the main therapeutic option for patients with health conditions such as atrial fibrillation, venous thrombosis, artificial heart valves and pulmonary embolus, which are associated with excess clotting risk that may cause adverse outcomes, including stroke and death. However, warfarin therapy is fraught with risk and liability. The drug interacts with food and many drugs and requires careful monitoring of the prothrombin time (PT) and international normalized ratio (INR).

Recently, when I applied for credentialing as solo practioner, I was asked by my medical malpractice insurer to detail my protocol for monitoring patients on anticoagulation therapy with warfarin. When I worked in group practice at the Emory Clinic in Atlanta I referred my patients to Emory’s Anticoagulation Management Service (AMS), which I found to be a wonderful resource. In fact, “disease management” clinics for anticoagulation are common amongst group practices because of the significant liability issues. Protocol based therapy and dedicated management teams improve outcomes for patients on anticoagulation with warfarin. Read more »

*This blog post was originally published at ACP Hospitalist*

Top Cardiology Stories Of 2010 And Predictions For 2011

The end of the year marks a time for list-intensive posts. Recently Larry Husten from CardioExchange and CardioBrief asked for my opinion on the three most important cardiology-related news stories of 2010. Additionally, he wanted three predictions for 2011. Here goes:

Top Cardiology Stories Of 2010:

1. By far, the #1 heart story of 2010 was the release of the novel blood-thinning drug dabigatran (Pradaxa) for the prevention of stroke in atrial fibrillation. Until this October, the only way to reduce stroke risk in AF was warfarin, the active ingredient in rat poison. Assuming that there aren’t any post-market surprises, Pradaxa figures to be a true blockbuster. Doctors and patients have waited a long time to say goodbye to warfarin.

2. The Dr. Mark Midei stent story: Whether Dr. Midei is guilty or innocent of implanting hundreds of unnecessary stents isn’t really the big story. The real impact of this well-chronicled saga is the attention that it brings to the therapeutic misconceptions of coronary stenting. The problem with squishing and stenting is that although they improve the physics (of bloodflow), they do not change the biology of arterial disease — a hard concept to grasp when staring at a picture of a partial blockage. The vast press coverage of Dr. Midei’s alleged transgressions has served to educate many about heart disease, the nation’s #1 killer. Read more »

*This blog post was originally published at Dr John M*

A Biofeedback Pen For Managing Stress

Miguel Bruns Alonso, a graduate student at Delft University of Technology in The Netherlands, has developed a pen that detects how much twitching and twirling it’s being put through.

People under stress tend to move and shake a pen more than someone who is calm. In order to try to get a therapeutic effect out of the pen, Bruns built in counter motion feedback that makes the pen a bit more difficult to move around. Though initial experiments have shown a marginal benefit, further studies and development may prove the benefit of the technology. From TU Delft:

Bruns, who studies industrial design, carried out various experiments during the course of his research, which showed that people tend to play with their pens in their hands when they are tense. It also seems that when they are encouraged to check these nervous movements, or make more gentle movements, it is possible to gain more control over a situation. “Sensors in a pen could provide an unobtrusive way of measuring stress levels. Giving users the right feedback could then help them deal with their stress in a constructive way,” says Bruns. Read more »

*This blog post was originally published at Medgadget*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

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I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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