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Improving patient care: the cognitive psychology of performance and prominence of diagnoses displayed by a clinical missed diagnoses purchase 50mg minocycline fast delivery on antibiotics for sinus infection. The promises and pitfalls of evidence- rates of autopsy-detected diagnostic errors over time: a systematic based medicine buy generic minocycline 50 mg on line virus yardville nj. Information seeking in primary care: how physicians and nurses: the ’micro-certainty, macro-uncertainty’ phe- physicians choose which clinical questions to pursue and which to nomenon. Physicians’ use of computer software in Should we confirm our clinical diagnostic certainty by autopsies? Diagnostic yield of the autopsy in a university hospital and a patient information during clinical care. Rationality in medical decision making: a ical guidelines: are there any ”magic bullets”? Premature conclusions in based guidelines on management of asthma and angina in adults in diagnostic reasoning. The epistemology of clinical reasoning: perspectives education activities change physician behavior or health care out- from philosophy, psychology, and neuroscience. Medical diagnostic decision support systems—past, Perceived causes of family physicians’ errors. A report card on computer-assisted diagnosis—the among high-risk specialist physicians in a volatile malpractice envi- grade: C. Billions for defense: the pervasive nature of defensive tics on perceptions of decision support systems. February 22, 2006 [published correction appears in The New cognitive model and empirical findings. A randomised public- potential impact of a reminder system on the reduction of diagnostic health trial on automation-assisted screening for cervical cancer in errors: a quasi-experimental study. Measuring the impact of diagnostic decision support on the quality of clinical decision mak- J Med. Learning from mistakes: factors that influence how students and J Am Med Inform Assoc. Effects of computerized physician order entry on prescribing medicine: what’s the goal? Training to improve calibration and discrimina- tion: the effects of performance and environment feedback. February 13, smears: how frequently are ”abnormal” cells detected in retrospective 2006:96–107. Overconfi- evolved to deal with 10,000 specific illnesses, all of which dence is one of the most significant of these biases. In both Effective problem solving, sound judgment, and well-cali- arenas, the first presentation of the illness is at its most brated clinical decision making are considered to be among undifferentiated. Alternately, the general this important area has been actively researched for only domain where the diagnosis probably lies is identified and about 35 years. The main epistemological issues in clinical the patient is referred for further evaluation. Much current work uncertainty progressively decreases during the evaluative in cognitive science suggests that the brain utilizes 2 sub- process. By the time the patient is in the hands of subspe- systems for thinking, knowing, and information processing: cialists, most of the uncertainty is removed. Their characteristics are listed in say that complete assurance ever prevails; in some areas 9 13 Table 1, adapted from Hammond and Stanovich. The system is fast, asso- For the purposes of the present discussion, we can make ciative, inductive, frugal, and often primed by an affective a broad division of medicine into 2 categories: one that component. Importantly, our first reactions to any situation deals with most of the uncertainty about diagnosis (e. These settings, therefore, deserve the closest scru- 13 situation (Table 2), and providing further characterization tiny. To examine this further, we need to look at the deci- of System 1 decision making.

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As a result purchase 50 mg minocycline free shipping antimicrobial nursing scrubs, dopamine’s For the brain cheap minocycline 50 mg overnight delivery virus 09, the difference between normal rewards and impact on the reward circuit of the brain of someone who drug rewards can be described as the difference between abuses drugs can become abnormally low, and that per- someone whispering into your ear and someone shouting son’s ability to experience any pleasure is reduced. Just as we turn down the volume on a This is why a person who abuses drugs eventually feels flat, radio that is too loud, the brain adjusts to the overwhelm- lifeless, and depressed, and is unable to enjoy things that were previously pleasurable. Also, the person will often need to take larger amounts of the drug to produce the familiar dopamine high—an effect known as tolerance. We know that the same sort of mechanisms involved in the development of tolerance can eventually lead to profound Healthy Control Drug Abuser changes in neurons and brain circuits, with the potential to severely compromise the long-term health of the brain. For 20 example, glutamate is another neurotransmitter that influences the W hat other brain changes reward circuit and the ability to learn. Chronic exposure to drugs of abuse disrupts the way critical brain Similarly, long-term drug abuse can trigger adaptations in habit or structures interact to control and inhibit behaviors related to drug use. Conditioning is one example of this Just as continued abuse may lead to tolerance or the need for higher type of learning, in which cues in a person’s daily routine or environ- drug dosages to produce an effect, it may also lead to addiction, which ment become associated with the drug experience and can trigger can drive a user to seek out and take drugs compulsively. Drug addic- uncontrollable cravings whenever the person is exposed to these cues, tion erodes a person’s self-control and ability to make sound deci- even if the drug itself is not available. This learned “reflex” is extreme- sions, while producing intense impulses to take drugs. Imaging scans, chest X-rays, and blood tests show the damaging effects of long-term drug Pabuse throughout the body. For example, research has shown that tobacco smoke causes cancer of the mouth, throat, larynx, blood, 19 lungs, stomach, pancreas, kidney, bladder, and cervix. In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system. Three of the Injection drug use is also a major factor in the spread of hepatitis more devastating and troubling consequences of addiction are: C, a serious, potentially fatal liver disease. Injection drug use is not z Negative effects of prenatal drug exposure on infants the only way that drug abuse contributes to the spread of infectious and children diseases. It is also likely that some drug- hepatitis B and C, and other sexually transmitted diseases. According to the Surgeon General’s 2006 Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, involuntary exposure to secondhand smoke increases the risks of heart disease and lung cancer in people who have never 20 smoked by 25–30 percent and 20–30 percent, respectively. Tobacco use is responsible for an estimated 23 5 million deaths worldwide each year. Tobacco smoke increases a user’s risk Throat of cancer, emphysema, bronchial disorders, and cardiovascu- Larynx (voice box) Mouth Esophagus lar disease. Tobacco use killed approximately 100 mil- Lung Blood (leukemia) lion people during the 20th century, and, if current smoking Stomach Kidney Pancreas trends continue, the cumulative death toll for this century has Bladder Cervix 24 been projected to reach 1 billion. However, misuse or abuse of these drugs (that is, taking impairs short-term memory and learning, the ability to focus attention, them other than exactly as instructed by a doctor and for the purposes and coordination. It also increases heart rate, can harm the lungs, prescribed) can lead to addiction and even, in some cases, death. Unfortunately, there is a common misperception that because medications are prescribed by physicians, they are safe even when used illegally or by another person than they were prescribed for. Users also may have traumatic experiences and ucts, such as oven cleaners, gasoline, spray paints, and other emotions that can last for many hours. It slows respiration, and its use is linked to an toxic and can damage the heart, kidneys, lungs, and brain. Even a increased risk of serious infectious diseases, especially when taken healthy person can suffer heart failure and death within minutes of intravenously. People who become addicted to opioid pain relievers a single session of prolonged sniffing of an inhalant. Serious consequences of abuse can z Amphetamines, including methamphetamine, are powerful stim- include severe acne, heart disease, liver problems, ulants that can produce feelings of euphoria and alertness. Methamphetamine’s effects are particularly long-lasting and harmful z Drug combinations.

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The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity purchase 50mg minocycline amex antibiotics for sinus infection types. Physicians are most satisfed as parents when ing physician health purchase 50mg minocycline visa steroids and antibiotics for sinus infection, including work-lifebalance, ways to they have a supportive spouse and when the work–home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians’ relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong’s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one’s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one’s partner, • explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to “say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers” (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that “he just doesn’t get it. Unbalanced criticism, defensiveness, Successful marriages and similar partnerships are built on ridicule, a posture of superiority, and “shutting off ” are poi- knowledge, friendship, fondness and admiration (Gottman sonous to this process (Hill and Love 2008). For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. It includes affection, expressiveness, sexuality, cohesion, compatibility, autonomy Dual-physician relationships and confict resolution (Myers 2001). Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the “emotional bank account” of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. Paradoxically, however, “the marital interests can be satisfying, which can lead to greater mutual relationship is the main source of coping with the stress of understanding, support and shared parenting (Schrager et al medical practice” (Gabbard 1989). It would seem, however, whether by preference, mutual decision or default, that women physicians continue to take Physicians who enjoy successful intimate partnerships learn more responsibility on the home front than their male counter- early that certain attributes that serve them well at work are parts. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians’ experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. As you develop your resident group or consider Relationships, however, do require work in realtime, a sense of your eventual practice setting, keep these questions in mind: humour, and a degree of luck. John Gottman, a respected re- • Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner’s attraction to logistics as simple as possible will beneft your marriage and “more medicine” and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor’s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too.

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To look at only one piece and try to understand the benefits and risks is like standing an inch away from an elephant and trying to describe everything about it generic minocycline 50mg amex antibiotics for acne south africa. Each specialty discount minocycline 50 mg on-line infection control training, each division of medicine keeps its own records and data on morbidity and mortality. We have now completed the painstaking work of reviewing thousands of studies and putting pieces of the puzzle together. Because of the extraordinarily narrow, technologically driven context in which contemporary medicine examines the human condition, we are completely missing the larger picture. Medicine is not taking into consideration the following critically important aspects of a healthy human organism: (a) stress and how it adversely affects the immune system and life processes; (b) insufficient exercise; (c) excessive caloric intake; (d) highly processed and denatured foods grown in denatured and chemically damaged soil; and (e) exposure to tens of thousands of environmental toxins. Instead of minimizing these disease-causing factors, we cause more illness through medical technology, diagnostic testing, overuse of medical and surgical procedures, and overuse of pharmaceutical drugs. The huge disservice of this therapeutic strategy is the result of little effort or money being spent on preventing disease. Underreporting of Iatrogenic Events As few as 5% and no more than 20% of iatrogenic acts are ever reported. In 1994, Leape said his figure of 180,000 medical mistakes resulting in death annually was equivalent to three jumbo-jet crashes every two days. What we must deduce from this report is that medicine is in need of complete and total reform—from the curriculum in medical schools to protecting patients from excessive medical intervention. It is obvious that we cannot change anything if we are not honest about what needs to be changed. We are fully aware of what stands in the way of change: powerful pharmaceutical and medical technology companies, along with other powerful groups with enormous vested interests in the business of medicine. They fund medical research, support medical schools and hospitals, and advertise in medical journals. Such funding can sway the balance of opinion from professional caution to uncritical acceptance of new therapies and drugs. You have only to look at the people who make up the hospital, medical, and government health advisory boards to see conflicts of interest. Erik Campbell, the lead author, said, "Our previous research with faculty has shown us that ties to industry can affect scientific behavior, leading to such things as trade secrecy and delays in publishing research. Marcia Angell struggled to bring greater attention to the problem of commercializing scientific research. In June 2002, the New England Journal of Medicine announced that it would accept journalists who accept money from drug companies because it was too difficult to find ones who have no ties. Jerome Kassirer, said that was not the case and that plenty of researchers are available who do not work for drug companies. Cynthia Crossen, a staffer for the Wall Street Journal, i n 1996 published Tainted Truth : The Manipulation of Fact in America , a book about the widespread practice of lying with statistics. In 1981 Steel reported that 36% of hospitalized patients experienced iatrogenesis with a 25% fatality rate, and adverse drug reactions were involved in 50% of the injuries. In 1991, Bedell reported that 64% of acute heart attacks in one hospital were preventable and were mostly due to adverse drug reactions. Leape focused on the “Harvard Medical Practice Study” published in 1991, (16a) which found a 4% iatrogenic injury rate for patients, with a 14% fatality rate, in 1984 in New York State. From the 98,609 patients injured and the 14% fatality rate, he estimated that in the entire U. Why Leape chose to use the much lower figure of 4% injury for his analysis remains in question. Using instead the average of the rates found in the three studies he cites (36%, 20%, and 4%) would have produced a 20% medical error rate. The number of iatrogenic deaths using an average rate of injury and his 14% fatality rate would be 1,189,576. Leape acknowledged that the literature on medical errors is sparse and represents only the tip of the iceberg, noting that when errors are specifically sought out, reported rates are “distressingly high. First, he found that each patient had an average of 178 “activities” (staff/procedure/medical interactions) a day, of which 1. This may not seem like much, but Leape cited industry standards showing that in aviation, a 0.

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