By R. Kadok. San Francisco State University.

The risks for disease and injury are as high—or link between work organization and mental health problems higher—for physicians as for other workers generic rabeprazole 10mg without prescription. Brian Day has stated buy rabeprazole 20 mg lowest price, “The health of Canada’s The economic benefts of promoting physician health should doctors is crucial to the provision of high-quality health care not be overlooked buy 10 mg rabeprazole fast delivery. In 2003–04, 34 per cent of the almost 2000 resident physicians Patient safety who participated in the Happy Doc pilot survey reported that Of obvious concern in relation to physician health and wellness their daily lives were “quite a bit” to “extremely” stressful. Physicians who are struggling with of respondents said they would pursue another career if they unmanaged mental or physical problems put both themselves could, and 53 per cent said that they had experienced intimida- and their patients at risk. Thus, an important stressor for physicians is The resident discussed with the program director family concern about their ability to provide optimal care for their stresses combined with a heavy clinical workload which patients (Wallace et al 2007). The director recommended a visit to the family management at McMaster University, “Exhaustion and illness doctor for assessment. No physical or mental illness was in the workplace can lead to errors in judgment, diffculty in detected. The family doctor recommended a balanced making decisions, increased social friction because of irritability diet, exercise and spending time with family. Andrew Padmos, chief executive offcer of the Royal of the Poststaff Health Organization). One month later College of Physicians and Surgeons of Canada, has stated that the resident is performing at their best and receives an “At the foundation of everything we do is one simple aim: to excellent evaluation on their rotation. According to the framework, is “the ability to achieve balance between work and personal the six core domains shared by all health care professionals are life. Younger physicians have indicated to: that they prefer to have good physical health rather than being • contribute to a culture of patient safety, stressed and tired out. For example, discussions with “new” physicians • optimize human and environmental factors, and highlight the value placed by this cohort on collegiality, open • recognize, respond to and disclose adverse events. Clear instructions Generational and gender differences during the orientation process help them to become more Recent research shows that “baby-boomer” and “Gen-X” effcient and confdent, translating into better teamwork and physicians work, on average, the same number of hours— encouraging collegiality. Young physicians also express a desire 61—per week and have a roughly equal level of commitment for a positive work culture, along with a wish to avoid being to patients. The biggest difference is that although Gen-Xers drawn into any existing pockets of cynicism. They agree that physicians feel that their medical careers are important, they any threat to their professional standards or that of a hospital “do not necessarily place [their work] at the forefront as the is potentially stressful and can affect their relationship with pa- only aspect of who they are. A culture of openness can help to mitigate these threats, younger cohort seeks a well-rounded and balanced life can be and a healthy sense of community among the physicians can interpreted by baby boomers as a lack of commitment (Jovic help physicians to cope with stressful situations. Bill Wilkerson, co-founder of the Global Business and The number of female physicians has increased 36. In the 2007 National Physician Survey, 80 per cent of physi- What is the solution in the workplace? Wilkerson puts it this cians indicated that the complexity of their patient caseload as way: “The solution is the cornerstone of good old-fashioned the biggest factor affecting their time. Given an ever-increasing management, which is based on human decency, clear think- proportion of our aging population is affected by chronic dis- ing, open communications. The other cornerstone is clarity of ease and comorbidities, the average physician’s workload will purpose and function. CanadianMedicalAssociation Of the medical students who responded to the 2007 National Launches First Check-up of Doctors’ Health. Society grants physicians status, respect, autonomy in practice, ability to self-regulate and fnan- cial compensation. In return, society has high expectations of Case physicians, including competence, altruism, ethical behaviour A physician is ill and chooses to take a day off from his and the delivery of a high standard of care. A number of patient visits are professional role physicians must make their patients’ well- rescheduled, and students and residents are assigned to being their frst priority, this commitment must include a caveat other supervisors. Physicians should bear in mind the advice ents the following week but begins the clinical encounter given to airline passengers in case of a depressurization: put by expressing dissatisfaction, anger and frustration that on one’s own oxygen mask before assisting others. We must the postponement of the appointment resulted in losing maintain our own health in order to be ft to care for society. The physician feels regretful and guilty at having taken the day off, but at the same time is frustrated by the patient’s demanding tone. Refection for educators At the beginning of your residents’ rotation, have them keep a journal of the challenges they encounter with Introduction respect to meeting the expectations of their patients and Society is quite aware of basic lifestyle choices that promote maintaining their own health. You may wish to provide good health, such as maintaining a healthy diet, exercising your own example of challenges you have experienced. In regularly, avoiding smoking and street drugs, and limiting addition, you can keep your own journal of such physician alcohol use. Most Canadians also recognize the importance of health challenges and have a formal discussion half-way working with their primary care physician for health concerns, through the rotation on how you and your residents dealt follow-up and appropriate screening at different stages of life. At their regular evaluation However, how often do patients consider the health needs of meetings program directors can discuss with residents the their own doctors? The journal will provide clear examples of how the residents understand Healthy physician, healthy patient the key issue. Residents may also consider incorporating Some patients infuence the mental health of their physicians such discussions into their half-day educational sessions by virtue of challenging personality traits, the denial of their or at their regular retreats. Physicians may choose to prescribe unneces- sary antibiotics for a viral illness to pacify the expectations of a patient who wants a quick resolution of their ailment. However, while these physicians are well aware of the lack of effcacy of antibiotics in these situations and the potential to promote new strains of resistant bacteria, they may feel they lack the time or energy to go through the process of proper patient education. The evolution of medicine into the computer era has also contributed to the complexity of the physician–patient relationship where physician health is concerned. Although one rarely hears of a house calls nowadays, e-mail is today’s equivalent of yesterday’s housecall. Patients can now follow doctors home, on vacation, or literally anywhere technology may go. What about the concept that patients need to be seen in person for a physician to make clinically informed deci- sions about their care? Today’s society expects medicine to be a convenient service, similar to the fast-food industry—which likely contributed to the development of the walk-in clinic. The patient appreciates the bedside: social expectations and value triage in medical practice.

In this particular case discount rabeprazole 20mg without a prescription, the probabilities add up to 100% since there are virtually no other diagnostic possibilities purchase 20mg rabeprazole. This is also knows as sigma p equals one cheap rabeprazole 20mg with amex, and applies when the diseases on the list of differential diagnoses are all mutually exclusive. Rarely, a person fitting this description will turn out to have gastric cancer, which occurs in less than 1% of patients presenting like this and can be left off the list for the time being. If none of the other diseases are diag- nosed, then one needs to look for this rare disease. In this case, a single diagnostic An overview of decision making in medicine 223 test, the upper gastrointestinal endoscopy, is the test of choice for detecting all four diagnostic possibilities. There are other situations when the presenting history and physical are much more vague. In these cases, it is likely that the total pretest probability can add up to more than 100%. This occurs because of the desire on the part of the physi- cian not to miss an important disease. Therefore, each disease should be con- sidered by itself when determining the probability of its occurrence. This proba- bility takes into account how much the history and physical examination of the patient resemble the diseases on the differential diagnosis. The assigned proba- bility value based on this resemblance is very high, high, moderate, low, or very low. In our desire not to miss an important disease, probabilities that may be much greater than the true prevalence of the disease are often assigned to some diagnoses on the list. Physicians must take the individual patient’s qualities into consideration when assigning pretest probabilities. For example, a patient with chest pain can have coronary artery disease, gastroesophageal reflux disease, panic disorder, or a combination of the three. In general, panic disorder is much more likely in a 20- year-old, while coronary artery disease is more likely in a 50-year-old. When con- sidering this aspect of pretest probabilities, it becomes evident that a more real- istic way of assigning probabilities is to have them reflect the likelihood of that disease in a single patient rather than the prevalence in a population. This allows the clinician to consider the unique aspects of a patient’s history and physical examination when making the differential diagnosis. Constructing the differential diagnosis The differential diagnosis begins with diseases that are very likely and for which the patient has many of the classical symptoms and signs. Next, diseases that are pos- sible are included on the list if they are serious and potentially life- or limb- threatening. These are the active alternatives to the working diagnoses and must be ruled out of the list. This means that the clinicians must be relatively certain from the history and physical examination that these alternative diagnoses are not present. Put another way, the pretest probability of those alternative diseases is so vanishingly small that it becomes clinically insignificant. If the history and physical examination do not rule out a diagnosis, then a diagnostic test that can reliably rule it out must be performed. Diseases that can be easily treated can also be included in the differential diagnosis and occasionally, the diagnosis is con- firmed by a trial of therapy, which if successful, confirms the diagnosis. Last to be included are diseases that are very unlikely and not serious, or are more difficult and potentially dangerous to treat. These diseases are less possible because they 224 Essential Evidence-Based Medicine Fig. A good example of this would be a patient with chest pain and no risk factors for pulmonary embolism who has a low transcu- taneous oxygen saturation. Now one should begin to look more closely for the diagnosis of pulmonary embolism in this patient. When considering a diagnosis, it is helpful to have a framework for consid- ering likelihood of each disease on one’s list. This only helps to get an overview and does not help one determine the pretest probability of each disease on the differential diagnosis. In this schema, each disease is considered as if the total probability of disease adds up to 100%. One must tailor the probabilities in one’s differential diagnosis to the individ- ual patient. Bear in mind that a patient is more likely to present with a rare or unusual presentation of a common disease, than a common presentation of a rare disease. As stated earlier, the first step in generating a differential diagnosis is to sys- tematically make a list of all the possible causes of a patient’s symptoms. This skill is learned through the intensive study of diseases and reinforced by clinical experience and practice. When medical students first start doing this, it is useful to make the list as exhaustive as possible to avoid missing any diseases. Think of all possible diseases by category that might cause the signs or symptoms. There are several helpful mnemonics that can help get a differential diagnosis started. The values of pretest probability are relative and can be assigned according to the scale shown in Table 20. Physicians are more likely to agree with each other on prioritizing diagnoses if using a relative scale like this, rather than trying to assign a numerical probability to each disease on the list. If the disease is immediately life- or limb-threatening, it needs to be ruled out, regardless of the probability assigned. If the likelihood of a disease is very very low, the diagnostician should look for evidence that the disease might be present, such as an abberrent ele- ment of the history, physical examination or diagnostic tests to suggest that the An overview of decision making in medicine 225 Table 20. Mnemonic to remember classification of dis- ease for a differential diagnosis V Vasc ular I Inflammatory/Infectious N Neoplastic/Neurologic and psychiatric D Degenerative/Dietary I Intoxication/Idiopathic/Iatrogenic C Congenital A Allergic/Autoimmune T T rauma E Endocrine & metabolic Table 20. Useful schema for assigning pretest (a-priori) probabilities Pretest probability Action Interpretation <1% Off the list – for now. But, must Rare disease (rare consider if other diseases later are presentation) found not to be present. This is a unique presentation of this disease, and therefore the patient can only have this disease. We will use this schema for selecting pretest probabilities for the rest of the book.

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Medical costs have increased dramatically over the last several decades effective rabeprazole 10 mg, in many cases in concert with improved care purchase rabeprazole 20mg on line, and it is clear that imaging has provided major advances in health care generic rabeprazole 20mg without prescription. Over the past few years, for a number of reasons, there has been increased concern about the exposure of populations and individuals to ionizing radiation. It is essentially impossible to define the individual risks and population risks are also virtually impossible to define with precision. Recent studies, however, have suggested that limited exposure to ionizing radiation does measurably increase the cancer risk for populations [12, 13]. There are, in summary, two important basic concepts that must be kept in mind: first, there is potential risk of exposure to diagnostic level ionizing radiation, so any use should be based on a risk– benefit analysis, with the possible benefits to be gained through the imaging outweighing the theoretical risks of ionizing radiation. Secondly, the concern about the possible adverse effects of radiation can be used to help educate the lay public, to enable them to consider the risk:benefit ratio whenever imaging (particularly using ionizing radiation) is considered. This concern logically leads to the conclusion that there is need for ongoing education and specific guidance in the optimal use of imaging, and this is probably best achieved and most likely to be successful if it is based on methodologically sound, widely accepted guidelines for the use of imaging. It follows, however, that imaging guidelines are likely to be very difficult to develop and deploy, given the complexity of modern medicine and the wide variations in disease patterns, availability of technology and treatments, and knowledge, but they are also necessary. There has been much discussion about how guidelines should be constructed, but there are several areas of wide consensus. First, clinical guidelines should be based to as large an extent as possible on high quality, peer reviewed literature. The available literature, however, is virtually never sufficient to provide data based guidance, except in very limited areas, so any guidelines must be data driven but supplemented by expert opinion. Guidelines must also be based on transparent, well defined, reproducible methodology that indicates how the literature is reviewed and synthesized, and how conclusions are reached. They must be developed and vetted by relevant experts, in this case imaging experts, as well as other health care providers, patients and even payers. They require specific expertise in the topic being addressed, as well as in methodology. Imaging guidelines differ from most other guidelines in that the focus is confined to guiding the ordering health care provider in the best use of imaging. They are, in a sense, horizontal, addressing all imaging, rather than vertical, addressing all aspects of a specific disease. Other widely accepted ones include those from the Royal College of Radiology of the United Kingdom [15], the Canadian Association of Radiologists and the Diagnostic Imaging Pathways from Western Australia [16]. Each panel has 8–20 members, with broad representation geographically and in modality expertise. Non-radiologist societies, such as the American College of Chest Physicians, the Society of Vascular Surgery and the American Society of Neurosurgery, have representatives on the panels. Currently, over 800 topics are addressed by specific appropriateness criteria and variants. Each topic is developed based on a perceived need, due to impact of disease, prevalence, cost implications and potential for impact on care and outcomes, as well as the availability of relevant peer reviewed studies in the published literature. Topics are developed by an assigned author who reviews, categorizes and selects and rates the relevant literature. An evidence table, consisting of the selected publications, is then created, which forms the basis for a narrative on the topic and presents and discusses all of the relevant imaging modalities. First, the panel chair and then the entire panel reviews all of this material, and then each modality in each variant is voted on for appropriateness. This is done using a modified Delphi approach, with three rounds of voting, one or two conference calls and consensus defined as 80% agreement of those voting. Rating is done on a scale of 1–9, with 1–3 defined as ‘usually not appropriate’, 7–9 as ‘usually appropriate’ and 4–6 as ‘may be appropriate’ (Fig. Each panellist is instructed to base their votes to as great an extent as possible on data, not personal experience. The study or procedure may be indicated in certain clinical settings, or the risk-benefit ratio for patients may be 4, 5, or 6 May be appropriate equivocal as shown in published peer-reviewed, scientific studies, supplemented by expert opinion. Under most circumstances, the study or procedure is unlikely to be indicated in these specific clinical settings, or Usually not 1, 2, or 3 the risk-benefit ratio for patients is likely to be unfavorable, appropriate as shown in published peer-reviewed, scientific studies supplemented by expert opinion. Either high quality, relevant clinical studies are not available or are inconclusive, or expert consensus could not Unrated No Consensus be reached regarding the use of this study/ procedure for this clinical scenario. American College of Radiology Appropriateness Criteria categories and definitions. These ratings are developed by a separate committee of radiation physicists and radiologists, and these ratings too are revised every 1–2 years, revisited as needed in the interim and are based to as great an extent as possible on high quality published, peer reviewed reports. First, as noted, for guidelines to be valid, they must be based on sound methodology, be updated regularly and be widely accepted. For example, there are areas covered by multiple guidelines, with differing recommendations, from different societies. Also, many doctors and payers, including insurance companies and regulatory agencies, would rather have direct control over the use of imaging, even if based on limited individual knowledge and experience. Finally, to really be useful, guidelines must cover most if not all clinical settings in which there is any question about the use of imaging, and they must be user friendly in terms of availability and utility. That is, useful and acceptable imaging guidelines must form a computer based decision support system. Example of an appropriateness criteria table, for one of six variants of the topic ‘low back pain’, with ratings for modalities and relative radiation level. The development of such a decision support system faces many challenges, including those of software development, hardware availability, system compatibility and interconnectivity, and availability of content with satisfactory breadth, depth and scientific validity. There are two major advantages to this: first, there is extensive prior experience with a clinical imaging decision support system which will help to inform the current effort. Usual practice varies widely from region to region, and nation to nation, as does the availability of equipment and the prevalence of disease, all of which influence the recommendations from a decision support system. While there are often clear justifications for performing diagnostic imaging examinations, there are many situations in which justification is more arguable. Determining what is justified is an extremely complicated aspect of medical practice as it potentially involves multiple health care providers, with varying levels of experience, anecdotal based decision making and a broad variety of other forces. It is beyond the intent of this paper to fully dissect this aspect of justification in medical imaging. However, there are tools that are becoming available for improving evidence based medicine, including decision rules, practice guidelines and appropriateness criteria, and point-of-care decision support. Many of these advancements are becoming embedded in electronic health care systems. The following material will present background information, define some of the terminology involved in ‘algorithms’ for improving justification, address the current status, provide some of the challenges in implementing models for improved justification of medical imaging, and present some of the current needs.

This book seeks to inspire a new generation of health- care professionals and managers to understand generic 20 mg rabeprazole visa, master buy rabeprazole 20 mg lowest price, and deploy these powerful new tools order 10 mg rabeprazole. Jeff Goldsmith May 2003 Preface xiii Acknowledgm ents Many people assisted in making this book possible. Neal Patterson, chairman and founder of Cerner Corporation, a pioneer- ing healthcare informatics firm, opened the door by inviting me to serve on Cerner’s board of directors. Gartner executives and analysts Jim Adams, Dave Garets (now of HealthLink), Janice Young, Thomas Handler, Wes Rishel, and Ken Kleinberg all contributed knowledge and ideas for this book. Christine Malcolm, formerly of Computer Sci- ences Corporation, now of Rush-Presybterian–St. On the hospital side, John Glaser, chief information officer at Partners HealthCare in Boston; David Blumenthal, director at the Institute for Health Policy and Physician at The Massachusetts Gen- eral Hospital/Partners HealthCare System; and Michael Koetting, vice president of planning at the University of Chicago Hospitals, were kind enough to read the manuscript and offer valuable advice on how to make it clearer, sharper, and more relevant. By happy coincidence, the University of Virginia is a hotbed of medical informatics activity and thought. Several Charlottesville colleagues helped early in the process to shape the book’s premise and focus on physicians. Robin Felder, professor of pathology and director of the University of Virginia’s Medical Automation Re- search Center, helped me understand the rapid advances in remote sensing technology and their future role in preventive health. On the scientific front, a fellow Cerner board member, William Neaves, president of the Stowers Institute; Paul Berg, professor emeritus of Stanford University; and George Poste, former chief scientific officer of Smith Kline Beecham, helped shed light on ad- vances in genetic diagnosis. Steven Burrill of Burrill and Company, a biotechnology investment bank, has produced superb analyses of the role of information technology in advancing genetic diagnosis and therapy. Finally, Anita Gupta ably assisted in the research on this book and the editing and preparation of this manuscript. Audrey Kaufman and Joyce Sherman of Health Administration Press provided valuable editorial comments and guidance. On his home page, in a special medical alert window, he found a reminder message from his physician, Dr. David, a 46-year-old computer software engineer, was in radiantly good health and had not seen his physician in 11 months. The reminder was part of a subscription agreement he had negotiated with her last year and was sent him automatically by Dr. Part of this agreement was a schedule of periodic monitoring of his health based on his genetic risk profile of potential health risks, including periodic blood tests. David did not need to leave his chair to have his blood analyzed; he simply placed his forefinger on a special touchpad attached to his office computer. A tiny laser beam in the touchpad scanned the blood particles passing through a capillary in his finger and digitally scanned his blood. The stream of digital information from David’s finger was in- stantly transmitted to the clinical laboratory in Dr. Kumar’s hos- pital, Springfield Memorial, through David’s broadband Internet connection. The identification and routing of his bloodwork was preset by the hospital’s computer system. This and all of David’s xvii other medical information was protected by an elaborate security system designed to shield both the sample and test results from scrutiny by anyone except David and his doctors. In the hospital’s laboratory, a sophisticated image recognition software program automatically read the image of David’s blood, counting and categorizing the different blood cells and comparing them to a visual template of normal blood. Kumar received her alert while she was eating breakfast at home and called David to ask if she could drop by to talk with him on her way to the office. These articles would bring her up to date on new research findings and innovative therapeutic alternatives for the disease. David was alarmed, although he knew that great strides had been made recently in leukemia treatment and that he was in good hands. Kumar reassured David that the count of abnormal white cells was still quite low, and based on what she knew, if laboratory xviii Introduction analysis confirmed the tentative diagnosis, chemoprevention would probably be the most effective first response. Kumar asked David if she could draw a sample of David’s blood to bring to the hospital laboratory to confirm or rule out the diagnosis. She told him that later that morning, he would learn a lot more by reading the attachments to her e-mail about their visit. Those attachments included a primer on the illness, a list of readings on its origins and treatment options, hypertext links to web sites on leukemia, as well as addresses of discussion groups for patients and families undergoing treatment for his disease. Salerno’s name from the consulting list, and with a touch of her stylus directed the hospital’s medical record system to transmit an abstract of David’s record and a sum- mary of the new laboratory results to Dr. Kumar direct the Springfield Memorial Hospital clinical laboratory to copy him on David’s blood analysis. Kumar arrange a three-way face-to-face meeting to discuss the treatment options and secure David’s per- mission to begin chemoprevention, the first step in the treatment process. Meanwhile, Springfield Memorial’s clinical laboratory analyzed David’s blood sample that morning with flow cytometry, a sophis- ticated, computer-guided cell-sorting tool; confirmed the diagnosis of leukemia; extracted a sample of leukemic cells from his blood; and isolated a genetic “fingerprint” of David’s leukemia to facilitate a possible second defense against the disease. Salerno was notified by computer alert of the con- firmation, he scheduled a meeting with David and Dr. Salerno ex- plained his view of the case and reviewed the consensus care pathway for David’s condition on his office computer. Kumar and promised to e-mail David a series of web site links and a record summary to ob- tain a second opinion electronically from an array of international cancer centers if he wished to do so. Salerno directed the hospital’s pharmacy by computer to prepare a chemopreventive infusion for David based on an analog of retinoic acid (a cousin of vitamin A). If it worked, this infusion would redirect the growth pathway of David’s leukemic cells, robbing them of their immortality. The infusion was delivered to David’s house by a home infusion therapy team from the hospital the following morning (Wednesday). Every day for the next three weeks, David would receive home infusion therapy, markedly strengthening David’s natural im- mune response to the disease. Meanwhile, David found a sympathetic reception in the on- line support group for leukemia patients and spent several hours a day online reading, searching, and asking and answering questions about his situation from new friends he found online. He also had several visits from his mother and sister, whom he had notified immediately of his problem. Every afternoon, David sent another “movie” of his blood to the Springfield Memorial lab to find out how his leukemia was responding.