Hello

Michael Grossman Michael.Grossman at MIHS.ORG
Thu Jan 21 16:36:14 UTC 2016


Drs. Brush and Yousef,
 it is a comfort to an octogenarian like me to witness the resurgence of thought and importance of the H&P. It is difficult to develop a list of "pre-test probabilities" without some foundation and thought. 
Thank you both for your clear and excellent comments

Michael Grossman MD MACP
Professor Internal Medicine and Bio Medical informatics University of Arizona
V.P. Academic Affairs Maricopa Integrated health System

-----Original Message-----
From: John Brush [mailto:jebrush at ME.COM] 
Sent: Thursday, January 21, 2016 7:38 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Hello

Dr. Yousef
Thank you for your excellent comments. You make some key points:
1. The H and P should be more than a template that provides documentation for billing. 
2. A differential diagnosis is a thought process not a Epic dot phrase. 
3. Things should be done in order. You should evaluate a patient, then order tests. 
4. Test results have quantifiable value. Some are more valuable than others. In a country with limited resources you were forced to think more on what really matters and choose tests more judiciously. 
5. Critical thinking and clinical reasoning are key but seem to be downplayed in America. 
6. Good doctors are "made," not born. Education has a role in improving diagnostic reasoning. Better education that focuses on reasoning skills is needed. 

Thanks again for your thoughtful and insightful observations. 
John Brush

Sent from my iPhone

> On Jan 21, 2016, at 8:27 AM, Elham Yousef <yousefe at CCF.ORG> wrote:
> 
> Dear listserv and SIDM members, Good Morning.
> 
> I am a new member with the SIDM and of course the listerv. 
> I just recently started to have an access to the listserv, and as I am trying to understand the dynamics of this communication and sharing thoughts and giving feedback, I figured it would be a good idea to introduce myself to all of you.
> 
> My name is Elham Yousef , I am a staff hospitalist at Cleveland clinic foundation, main campus. I share the same passion as all of you - to make diagnosis safe , accurate and timely for our patients. they put their trust and confidence in us and we have no choice but to be up to the level of trust.
> 
> I agree that the challenges are huge,  complicated , and deep rooted, but I believe the most imported step is to figure out how we got there in the first place and then figure out why ???
> 
> being an Egyptian native, studying medicine their was very fascinating, medical school is 6 1/2 years right after high school , followed by one year as a house officer and after completing the 7 1/2 years we obtain our medical degree, after that we go for 3 years of residency and the rest is just like here in US.
> 
> what made studying medicine very fascinating in Egypt, is that- because it's a 3rd world country, majority of people are uninsured, dysfunctional health care system and corrupted government- the main focus was how to "make" physicians who are capable of making accurate diagnosis by taking a very comprehensive history, perform comprehensive physical examination and create an accurate differential diagnosis with the least possible resources ( labs, images, procedures) because patients will have to pay for all diagnostic work up,  with a very high poverty rate , telling a patient that " good news your CT was normal will make him/her ask you why did you need to order it in the first place, i had to borrow the money for that'- which was absolutely not acceptable.
> 
> I think because we were all economically oriented of the social status of the majority of our patients, we invested our time, effort on physical examination, differential diagnoses, critical thinking and clinical reasoning more than any thing.
> 
> After moving to America 15 years ago, and going through another residency, I started to learn/ study a completely different medicine. H&P became just a template , we complete it for the purpose of documentation, ordering work up and reviewing it even before talking the  patient was the normal and I have to say that this was my " true medical cultural shock", 15 years later I still can't get over that shock !!
> 
> Of course I understand to some extent why it is like this here and why it is like that in Egypt. I am not saying that Egypt is the best or US is the worse, absolutely not , that's not my point but because I have the privilege of being part of 2 different medical cultures, I just can't help it but to compare with a goal of trying to get the best out of those 2 cultures and this makes me very fortunate.
> 
> I think we lost track of the true purpose of H&P, the true indication for diagnostic work up, what it means to be a critical thinker, we lost track of the true medicine and what it mean to be a good doctor.
> 
> 
> SIDM is all about putting us back on the right track, do what is right for our patient, see them as human, treat them as human, talk to them as human, engage them as human, respect them as human because they are human who just happened to be patients.
> 
> In Egypt, they used to call the doctor " Hakeem" which mean the " wise man" and this is what we need now, to become " hakeem ( male)  and hakeema ( female).
> 
> Thank you all for your time.
> 
> Thank you for accepting me as new member and for giving me such an honor to make a difference.
> 
> Elham
> 
> 
> 
> 
> 
> 
> 
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in 
> Medicine
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