Jan L. C. M. van Saase

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert.

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.

N-terminal pro–brain natriuretic peptide testing in the emergency department: Beneficial effects on hospitalization, costs, and outcome

BACKGROUND N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. Assessment of this biomarker in patients with acute dyspnea presenting to the emergency department (ED) may aid diagnostic decision-making, resulting in improved patient care and reduced costs. METHODS In a prospective clinical trial, patients presenting with acute dyspnea to the ED of the Erasmus Medical College, Rotterdam, the Netherlands, were randomized for either rapid measurement or no measurement of NT-proBNP. For ruling out heart failure, cutoff values of 93 pg/mL in male and 144 pg/mL in female patients were used, and for ruling in heart failure, a cutoff value of 1,017 pg/mL was used. Time to discharge from the hospital and costs related to hospital admission were primary end points. Bootstrap analysis was used for comparison of costs and 30-day mortality between the NT-proBNP and control group. RESULTS A total of 477 patients (54% male) was enrolled. The mean age was 59 years, with 44% of patients having a history of cardiac disease. Median time to discharge from the hospital was 1.9 days (interquartile range [IQR], 0.12-8.4 days) in the NT-proBNP group (n = 241) compared with 3.9 days (IQR, 0.16-11.0 days) in the control group (n = 236) (P = .04). Introduction of NT-proBNP testing resulted in a trend toward reduction in costs related to hospital admission and diagnostic investigations of

Infections after renal allograft failure in patients with or without low-dose maintenance immunosuppression.

1,364 per patient (95% CI

Encounters between medical specialists and patients with medically unexplained physical symptoms; influences of communication on patient outcomes and use of health care: a literature overview.

-246 to

A cross-sectional study of age-related loss of mineral content of phalangeal bone in men and women

3,215), whereas 30-day mortality was similar (15 patients in the NT-proBNP and 18 patients in the control group). CONCLUSIONS Introduction of NT-proBNP testing for heart failure in the ED setting reduces the time to discharge and is associated with a trend toward cost reduction.

Progressive multifocal leukoencephalopathy, a review and an extended report of five patients with different immune compromised states.

BACKGROUND Failed renal allografts are sometimes left in situ for additional clearance and urine production during hemodialysis or peritoneal dialysis, and low-dose immunosuppressive medication is often continued in such patients. We compared the morbidity and mortality due to infections between patients with (group A) or without (group B) low-dose immunosuppression (i.e., transplantectomy). METHODS In a hospital-based cohort study, we analyzed data from patient files. We evaluated 37 patients who received 42 kidney transplantations between May 1975 and November 1995. RESULTS A total of 2.28 vs. 0.68 infections/patient-year were found in groups A and B, respectively. The odds ratio of one or two infections developing for patients in group A compared with group B was 14.2 (95% confidence interval, 1.4-143.4; P<0.025) and 4.3 (95% confidence interval, 1.1-17.3; P<0.04). A total of five lethal infections were found in group A; no lethal infections were found in group B. CONCLUSIONS The increase in serious and life-threatening infections associated with even low-dose immunosuppression argues in favor of discontinuation of these drugs. The removal of failed renal allografts should be considered.

Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases

Medically unexplained physical symptoms (MUPS) burden patients and health services due to large quantities of consultations and medical interventions. The aim of this study is to determine which elements of communication in non-psychiatric specialist MUPS care influence health outcomes. Systematic search in PubMed, PsycINFO and Embase. Data extraction comprising study design, patient characteristics, number of patients, communication strategies, outcome measures and results. Elements of doctor-patient communication were framed according to symptoms, health anxiety, satisfaction, daily functioning and use of health care. Eight included studies. Two studies described the effect of communication on patient outcome in physical symptoms, three studies on health anxiety and patient satisfaction and one study on daily functioning. Two studies contained research on use of health care. Qualitative synthesis of findings was conducted. Communication matters in non-psychiatric MUPS specialist care. Perceiving patients’ expectations correctly enables specialists to influence patients’ cognitions, to reduce patients’ anxiety and improve patients’ satisfaction. Patients report less symptoms and health anxiety when symptoms are properly explained. Positive interaction and feedback reduces use of health care and improves coping. Development of communication skills focused on MUPS patients should be part of postgraduate education for medical specialists.

Why do doctors make mistakes? A study of the role of salient distracting clinical features.

The bone mineral content of the second phalanx of the second digit was studied by quantitative microdensitometry. It is concluded that age-dependent loss of bone is a generalised phenomenon in men and women that occurs at different rates at different ages. In women, an accelerated rate of bone loss is observed between 50 and 57 years of age; in men such an acceleration is observed after 68 years of age. It appears that in a selected “ideal” population (with no disease or medication that may influence bone metabolism) the rate of bone mineral loss in women of 50–57 years of age is greater than in an unselected normal population. Furthermore, especially in the 50–57 years age group, the rate of loss at the midshaft of the phalanx in women is higher than at a site 25% from the proximal end. In men the rate of bone mineral loss at the 25% site exceeds that at midshaft, especially in the 68–75 year age group.

Do patients’ disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the brain caused by the JC-virus. Both a decreased cellular or humoral immune response can increase the susceptibility for JC-virus induced PML. Not only HIV infected people are at risk, a wide range of otherwise immune compromised patients are a potential target for this virus. This report of five PML patients shows the importance of a clinicians familiarity with this disease and its presenting symptoms. The presenting symptoms of PML can sometimes mimic worsening of the underlying disease. Although different therapeutic strategies have been tried, the outcomes remain very poor. In this series, treatment with cidofovir appears not to be effective in treating PML, neither in HIV positive nor HIV negative patients. Experimental therapy with leflunomide, after tapering of the immunosuppressive medication, did change the natural course of PML in one patient.

Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment

Purpose Anecdotal evidence indicates that exposure to media-distributed disease information, such as news about an outbreak, can lead physicians to errors; influenced by an availability bias, they misdiagnose patients with similar-looking but different diseases. The authors investigated whether exposure to media-provided disease information causes diagnostic errors and whether reflection (systematic review of findings) counteracts bias. Method In 2010, 38 internal medicine residents first read the Wikipedia entry about one or another of two diseases (Phase 1). Six hours later, in a seemingly unrelated study, they diagnosed eight clinical cases (Phase 2). Two cases superficially resembled the disease in the Wikipedia entry they had read (bias expected), two cases resembled the other disease they had not read about (bias not expected), and four were filler cases. In Phase 3, they diagnosed the bias-expected cases again, using reflective reasoning. Results Mean diagnostic accuracy scores (Phase 2; range: 0–1) were significantly lower on bias-expected cases than on bias-not-expected cases (0.56 versus 0.70, P = .016) because participants misdiagnosed cases that looked similar to a Wikipedia description of a disease more often when they had read the Wikipedia description (mean = 0.61) than when they had not (mean = 0.29). Deliberate reflection (Phase 3) restored performance on bias-expected cases to pre-bias levels (mean = 0.71). Conclusions Availability bias may arise simply from exposure to media-provided information about a disease, causing diagnostic errors. The bias’s effect can be substantial. It is apparently associated with nonanalytical reasoning and can be counteracted by reflection.