StudentDoctora

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I know that this is probably a weird question, but I've been thinking about it lately. How do physicians know (just from a few symptoms and a physical exam), A) what to look for, B) what tests to do, C) how to interpret those tests, D) what treatment to offer, E) etc..... Does it just come naturally after a certain point? Do you just go with intuition? Or is there a serious amount of debating (within your own head) about it could be this, but it couldn't be this, but if this comes back positive then it could be this, etc.?

I just wonder if I'd ever be able to truly do that! With computers, for example, it's almost automatic how I think... I don't have any formal computer science training or anything, but just from my own trail and error, I can usually figure out how to do something and/or what is wrong with it. Someone will tell me "my computer has a little box popping up in the corner," and I just instinctively know which questions to ask, and based on their answers, I usually know the problem and how to fix it.

Does medicine work in the same way (OBVIOUSLY much more complicated, but I mean, does it have sort of the same thought process?)?? THANKS so much for any opinions! :D:D:D
 

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Magic.
 

mjl1717

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This is not an easy q, but Ill start...

1)It helps being a pathology monster/master..

2)The art of "critical thinking" or Oslerian thinking should be mastered..

3)The differential diagnosis should rule in or rule out either autoimmune/ rheumatoid, malignancy, infectious or circulatory disturbances..

4)Last but not least (although its minimized on the forum) STRONG communication skills during history taking can usually aid in diagnosing..

5)Clinical accumen increases as one increase his experience..There is probably more.. Ill let the others chime in..

:idea:
 
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shreypete

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There always residency....where you get a lot of clinical exposure and deal with many types of cases (both similar and different from each other)
 

cpants

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From the first contact with the patient you are developing a differential diagnosis in your head. This is basically a list of all the possible things the patient could have based on his chief complaint. As the history and physical progresses you rule things out and modify how likely you think each diagnosis could be. After you finish the exam you should have your diagnosis, or at least a few likely possibilities which can be confirmed or denied with labs/imaging.

Example:
Patient presents with chest pain.
Differential will include:
Myocardial infarction
Angina
Pulmonary Embolism
Pneumonia
Trauma
Cancer
And a ton of other stuff.

You can narrow the diagnosis really quickly with a few simple questions. Was this pain sudden or gradual onset? Do you have any shortness of breath? Have you ever experienced something like this before? What other symptoms do you have (cough, hemoptysis, exercise intolerance, etc.)? After narrowing it down, you order labs/images to confirm your diagnosis.

After a ton of experience, a doctor probably isn't consciously running through the differential, but the basic technique remains the same.
 

masterofmonkeys

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From the first contact with the patient you are developing a differential diagnosis in your head. This is basically a list of all the possible things the patient could have based on his chief complaint. As the history and physical progresses you rule things out and modify how likely you think each diagnosis could be. After you finish the exam you should have your diagnosis, or at least a few likely possibilities which can be confirmed or denied with labs/imaging.

Example:
Patient presents with chest pain.
Differential will include:
Myocardial infarction
Angina
Pulmonary Embolism
Pneumonia
Trauma
Cancer
And a ton of other stuff.

You can narrow the diagnosis really quickly with a few simple questions. Was this pain sudden or gradual onset? Do you have any shortness of breath? Have you ever experienced something like this before? What other symptoms do you have (cough, hemoptysis, exercise intolerance, etc.)? After narrowing it down, you order labs/images to confirm your diagnosis.

After a ton of experience, a doctor probably isn't consciously running through the differential, but the basic technique remains the same.
Number 1 cause of chest pain in an academic (i.e. underserved) hospital/ER setting is either GERD or nothing. At least that's been my experience.
 

Tired

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Number 1 cause of chest pain in an academic (i.e. underserved) hospital/ER setting is either GERD or nothing. At least that's been my experience.
I nominate this for the most pretentious post of the day.
 

Jwax

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PeepshowJohnny

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It's a combination of book learning (Here, memorize this list of things that can cause anemia), pattern recognition (Hmm, yep, this kid sure looks like he's got RSV), probability (think horses, not zebras) and luck.
 

masterofmonkeys

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It's a combination of book learning (Here, memorize this list of things that can cause anemia), pattern recognition (Hmm, yep, this kid sure looks like he's got RSV), probability (think horses, not zebras) and luck.
yep
 
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Law2Doc

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Do you just go with intuition?
Intuition should never enter into it. Your question above is why medical TV shows are a bit dangerous to society -- people, including premeds, actually think that doctors act like this. But in fact, doctors don't, or shouldn't, act like House in the later seasons and jump to dangerous tests on a whim. The right approach is to come up with a list of possible diagnosis based on the symptoms, and then do tests calculated to limit the possibilities on that list. It should be evidence based, not guesswork. You rule out dangerous things first, and common things being common is the general rule. But intuition is never part of it. If you cannot articulate a reason for the diagnosis you have chosen, it's not acceptable medicine.
 

Law2Doc

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I believe the more that patients believe this, the greater the positive placebo effect...
No -- the more people that believe this, the more people that will opt for herbal remedies in lieu of evidence based treatments. You'd be trading all of medicine for placebo, which is what we had in the 1500s, and people died in scores from a lot of very curable things.
 

cpants

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Intuition should never enter into it. Your question above is why medical TV shows are a bit dangerous to society -- people, including premeds, actually think that doctors act like this. But in fact, doctors don't, or shouldn't, act like House in the later seasons and jump to dangerous tests on a whim. The right approach is to come up with a list of possible diagnosis based on the symptoms, and then do tests calculated to limit the possibilities on that list. It should be evidence based, not guesswork. You rule out dangerous things first, and common things being common is the general rule. But intuition is never part of it. If you cannot articulate a reason for the diagnosis you have chosen, it's not acceptable medicine.
The only place intuition does enter in is when you get your general impression of the patient. Sometimes you can just see someone and you know they are in serious trouble, and you better help them quickly.
 

ZagDoc

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It's a combination of book learning (Here, memorize this list of things that can cause anemia), pattern recognition (Hmm, yep, this kid sure looks like he's got RSV), probability (think horses, not zebras) and luck.
QFT. We had an interesting talk the other day on the "progression of thinking through the DDx at various stages of training." I was surprised it had even been studied.

The results from the study showed that clinicians evolve from active analytical thinking to pattern recognition. First and second year students have "classroom bias" to their thoughts in clinics, pulling from the subjects they feel strongest in and know the most about, which is more often than not what they are currently covering in lecture. Older students/interns tend to actively "think through" each case, ordering possibilities into systems and processes and going through a process of elimination and pulling information from long term memory. Eventually it becomes pattern recognition, with the information needed coming from short term access memory. It's not "intuition," its still knowledge, it's just coming from a different part of memory. You ask an intern how they came to a diagnosis, they can tell you what steps they went through to arrive at their conclusion (they had non-exertional chest pain radiating to neck, nocturnal symptoms, history consistent with heartburn, responded to trial of PPIs). You ask a practicing physician of 30 years how they arrived at a diagnosis, they can't tell you, they just "know." (That's a GERD patient.) The study also found that when experienced physicians come across a patient with contradictory or confusing signs/symptoms/history, they revert back to the old process of active thinking and logical thought (pulling causes of non-exertional chest pain from long term memory if Hx and PE are inconsistent with GERD).

Of course, you can't even start with the active process until you learn enough about diseases, tests, processes, symptoms, etc ad nauseum. That's the so called hurdle of transitioning from the lecture room of the pre-clinical years to MS3 and beyond. It's all practice, experience, blah, blah, blah.
 
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Law2Doc

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The only place intuition does enter in is when you get your general impression of the patient. Sometimes you can just see someone and you know they are in serious trouble, and you better help them quickly.
True, but even then, you are probably still objectively evaluating such person in terms of whether they look septic etc as compared to the scores of others you have seen in that condition, rather than using "intuition", in most cases.
 

Scaredshizzles

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No -- the more people that believe this, the more people that will opt for herbal remedies in lieu of evidence based treatments. You'd be trading all of medicine for placebo, which is what we had in the 1500s, and people died in scores from a lot of very curable things.


It's weird, but I used to think very highly of the advice doctors would give to me as a child and used to think their diagnosis was absolutely correct. The more medicine I learned, the less faith I was left with. The placebo effect might account for half of the efficacy of even modern medical treatment. (in fact I've been taught that the psychotropic drugs for depression and anxiety have been evidenced by many studies to have placebo effect account for 50% of their efficacy.) But unfortunately a consequence of medical training is that you lose the power of the placebo effect on yourself...you start questioning your doctor's every decision and don't have as much faith that recommendations will work.

Perhaps magic is the wrong term, but I think the more faith and confidence patients have in you as an all knowing being of medicine, the greater the effect of the treatment. I think a positive placebo effect is something that should be harnessed for good, not shunned away because our physiology and pharmacology studies can't account for it.
 

sirus_virus

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It's not like most diagnosis involve a lot of brain power. Most doctors diagnose the same things multiple times a day.
 

mjl1717

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It's not like most diagnosis involve a lot of brain power. Most doctors diagnose the same things multiple times a day.
You suggest "life is easy" in a very litiginous society--I strongly disagree.

Im talking about ALWAYS thinking about the most common, versing the most lethal and possibly what is most obscure.. I cant say this any clearer.. Im talking about a "real doc"..
Not a greedy, calloused, unconscientious CEO willing to risk economic disaster.

:thumbdown:
 
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sirus_virus

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You suggest "life is easy" in a very litiginous society--I strongly disagree.

Im talking about ALWAYS thinking about the most common, versing the most lethal and possibly what is most obscure.. I cant say this any clearer.. Im talking about a "real doc"..
Not a greedy, calloused, unconscientious CEO willing to risk economic disaster.

:thumbdown:
That is why you stick to the standard of care and generally accepted practices. Trying to reinvent the wheel on the fly will get you sued faster. In fact, treating your pts with lots of respect will prevent lawsuits way more than turning them into mini investigative research projects.
 

45408

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It's a combination of book learning (Here, memorize this list of things that can cause anemia), pattern recognition (Hmm, yep, this kid sure looks like he's got RSV), probability (think horses, not zebras) and luck.
Exactly. If you're a pediatrician, and you've had a dozen kids roll in with RSV, and then you have a patient come in that has the exact same presentation and doesn't look too ill, you should start to see a pattern...

There will be some trial and error. Not every patient will respond the way that your textbook says they should, so you try your second-line drugs or do another round of tests. Like others mentioned, it's also based on experience. Not so much intuition, but rather just being able to recognize when a child/adult is truly ill versus something that is inconsequential.
 

Law2Doc

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It's weird, but I used to think very highly of the advice doctors would give to me as a child and used to think their diagnosis was absolutely correct. The more medicine I learned, the less faith I was left with. The placebo effect might account for half of the efficacy of even modern medical treatment. (in fact I've been taught that the psychotropic drugs for depression and anxiety have been evidenced by many studies to have placebo effect account for 50% of their efficacy.) But unfortunately a consequence of medical training is that you lose the power of the placebo effect on yourself...you start questioning your doctor's every decision and don't have as much faith that recommendations will work.

Perhaps magic is the wrong term, but I think the more faith and confidence patients have in you as an all knowing being of medicine, the greater the effect of the treatment. I think a positive placebo effect is something that should be harnessed for good, not shunned away because our physiology and pharmacology studies can't account for it.
I think a big part of this is that a sizable percentage of people who seek out medical assistance have nothing really medically wrong with them. Or, as you suggest, a non-real or emotional component associated with an otherwise real psych diagnosis. So for those folks a placebo cure works fine -- if you have a questionable ailment, then a fake treatment may be appropriate. However if there is something actually wrong with you, then no, the placebo effect won't account for 50% of efficacy - more like 0.5%. You won't cure cancer or diabetes or heart disease or a brain aneurism with a placebo, but you might cure idiopathic aches and pains. And you won't cure depression or a panic disorder with a placebo, but in conjunction with an actual remedy for those issues, you might address some of the non-medical, emotional issues with a placebo effect. So I wouldn't put much faith in the placebo effect as a medical cure -- the cure tends to be as real as the ailment. Which again doesn't mean it doesn't address the issues of some of the patients who will come into your office.

But as I mentioned above, embracing things like placebo effect in lieu of evidence based things is quite dangerous. Because the public doesn't get that some things are real problems that need to be addressed, and other things are emotional issues that can be addressed with placebo because there is nothing actually treatable with evidence based medicine. But if you go down the road of magic cure-alls, you blur the distinction between medicine and magic. You give validity to non-evidence based things, and pretty soon patients will start going to the naturopath who gives them the same placebo herbs at half the price. But sometimes these patients have very real things for which placebo shouldn't be used. Sometimes a back ache is just a back ache, sometimes it's metastatic cancer. It may not be appropriate to treat the latter with placebo. But if you embrace placebo as part of medicine you lessen the odds that patients will turn to the medical establishment for their treatment because non-physicians are just as good at giving out fake treatments as doctors, and can do it cheaper.

So this is a very dangerous road for physicians, and not one to be embraced or encouraged.
 
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