Medical Decision-Making Keith Bradley MD Director Research Associates

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Medical Decision-Making Keith Bradley, MD Director Research Associates Program at St. Vincent’s National Alliance of RA Programs

Three (3) Modes of Diagnosis • Pattern Recognition (“Augenblick”) • Branching • Matching

Augenblick “blink of an eye” See it; know it

ABC’s • A = asymmetric • B = border irregular • C = color black or variable • D = diameter > 1/4”

Branching

Branching e. g. , Chest Pain

Branching e. g. , Chest Pain • “expert”

Branching e. g. , Chest Pain • “expert” • “blinders”

Branching e. g. , Chest Pain • “expert” • “blinders” • potential for error

Branching e. g. , Chest Pain • “expert” • “blinders” • potential for error • “practice”

Matching

Matching • ALL possible diagnoses on x-axis

Matching • ALL possible diagnoses on x-axis • Each possible – symptom – sign – investigation result on y-axis

Matching • ALL possible diagnoses on x-axis • Each possible sx, px, tx on y-axis • = Excel spreadsheet

Matching • ALL possible diagnoses on x-axis • Each possible diagnoses on y-axis • = Excel spreadsheet • Lawrence Weed, MD / “couplers”

Different Types of Problems Different Types of Responses

Non-Traumatic Unconsciousness

Non-Traumatic Unconsciousness • Airway

Non-Traumatic Unconsciousness • Airway • Breathing

Non-Traumatic Unconsciousness • Airway • Breathing • Circulation

Non-Traumatic Unconsciousness • • Airway Breathing Circulation Defibrillate

Types of Problems Types of Responses Problem Acute Response Rapid, simple, memorized

Fever, Ear Pain in a 3 year old

Fever, Ear Pain

Fever, Ear Pain • Dx = acute otitis media • Tx = depending on timing: nothing or Abs

Types of Problems Types of Responses Problem Acute Response Routine Rapid, simple, memorized Routine, stylized

“My leg is swollen”

“My leg is swollen” • What would Dr. House do?

“My leg is swollen” • What would Dr. House do? • DDx

“My leg is swollen” • What would House do? • DDx • Key Question … never forget to ask = ?

“My leg is swollen” • • What would House do? DDx Key Question … never forget to ask Be the star!

“My leg is swollen” • • What would House do? DDx Key Question … never forget to ask Be the star! – thick smear … draw blood at night

“My leg is swollen” • Dx = filiariasis

“My leg is swollen” • Dx = filiariasis • Tx = anti-helminths or …

“My leg is swollen” • Dx = filiariasis • Tx = anti-helminths or … – The parasites responsible for filariasis have a population of symbiotic bacteria, Wolbachia, that live inside the worm. – When the symbiotic bacteria are killed by the antibiotic, the worms themselves also die. • Doxycycline might be effective – Clinical trials in June 2005 by the Liverpool School of Tropical Medicine reported that an 8 week course almost completely eliminated microfilariaemia. [4][5]