Download Harrison's Principles of Internal Medicine, 16th edition by Dennis L. Kasper PDF

By Dennis L. Kasper

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Additional resources for Harrison's Principles of Internal Medicine, 16th edition

Example text

Analysis of the differential diagnosis is an iterative process. As new information or test results are acquired, the group of disease processes being considered can be contracted or expanded appropriately. Despite the importance of evidence-based medicine, much of medical decision-making relies on judgment— a process that is difficult to quantify or even to assess qualitatively. Especially when a relevant evidence base is unavailable, physicians must use their knowledge and experience as a basis for weighing known factors along with the inevitable uncertainties and then making a sound judgment.

The accuracy of a given test is ascertained by determining its sensitivity (true positive rate) and specificity (true negative rate) as well as the predictive value of a positive and negative result. Bayes’ theorem uses information on a test’s sensitivity and specificity, in conjunction with the pretest probability of a diagnosis, to determine mathematically the posttest probability of the diagnosis. More complex clinical problems can be approached with multivariate statistical models, which generate highly accurate information even when multiple factors are acting individually or together to affect disease risk, progression, or response to treatment.

In such cases, it is particularly important for the patient to understand clearly the risks entailed in these procedures; this is the definition of informed consent. It is incumbent on the physician to explain the procedures in a clear and understandable manner and to ascertain that the patient comprehends both the nature of the procedure and the attendant risks. The dread of the unknown that is inherent in hospitalization can be mitigated by such explanations. Incurable Disorders and Death No problem is more distressing than that presented by the patient with an incurable disease, particularly when premature death is inevitable.

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