Diagnostic Judgments Research Articles

Making the diagnosis of labour: midwives’ diagnostic judgement and management decisions

This paper reports a study examining midwives' perceptions of the way in which they diagnose labour. Diagnosis of active labour is often problematic. A midwifery workforce planning tool identified that up to 30% of women admitted to United Kingdom labour wards subsequently turned out not to have been in labour. There is evidence that if a woman is admitted to a labour ward in early labour, she is more likely to have some form of medical intervention. However, despite the impact of misdiagnosis, there is little research on the process of decision-making by midwives in relation to diagnosis of labour. This was a qualitative study, employing focus group methods. Participants were a convenience sample of midwives working in a maternity unit in the North of England during 2002. They were asked to discuss their experience of admission of women in labour. Data were analysed using latent content analysis. Thirteen midwives participated in one of two groups. They described using information cues, which could be separated into two categories: those arising from the woman (Physical signs, Distress and coping, Woman's expectations and Social factors) and those from the institution (Midwifery care, Organizational factors and Justifying actions). Midwives' decision-making process could be divided into two stages. The diagnostic judgement was based on the physical signs of labour: the management decision would then be made by considering the diagnostic judgement as well as cues such as how the woman was coping, her expectations and those of her family and the requirements of the institution. Midwives may experience more difficulty with the management decision than with the initial diagnosis. It may be that the number of inappropriate admissions to labour wards could be reduced by supporting midwives to negotiate the complex management hurdles, which accompany diagnosis of labour.

Should the Modern Language Aptitude Test Be Used to Determine Course Substitutions for and Waivers of the Foreign Language Requirement?

Abstract: Colleges and universities often permit students classified as learning disabled (LD) and other students not classified as LD to substitute courses for or waive the foreign language requirement. The Modern Language Aptitude Test (MLAT) has become an increasingly popular assessment tool to determine which students can or cannot pass foreign language courses and to diagnose a for foreign language learning. However, the use of the MLAT for these purposes has both theoretical and psychometric problems. These problems include misusing the MLAT to diagnose a learning disability or to classify students with a disability for foreign language learning; using a single test score to recommend course substitutions and waivers; using outdated test norms; and misunderstanding of the foreign language aptitude concept. The authors conclude by describing appropriate and inappropriate uses of the MLAT. Key words: course substitutions, foreign language aptitude, foreign language requirement, foreign language waivers, MLAT Language: Relevant to all foreign languages Introduction For several years, colleges and universities have permitted students classified as learning disabled (LD), as well as other students not classified as LD, to substitute courses for or to waive the foreign language requirement (Shaw, 1999; Sparks & Javorsky, 1999a; Sparks, Philips, & Ganschow, 1996). Although there is limited data on the frequency with which course substitutions and waivers are used, two recent studies at one university found that the number of course substitutions for the foreign language requirement had increased by 300% over a 5-year period from 1995 to 2000 (Sparks, Philips, & Javorsky 2002, 2003). In a recently completed survey of 101 two- and four-year U.S. colleges and universities, Driscoll (2003) found that 76% of the institutions permitted students to substitute courses for the foreign language requirement and 19% allowed students to waive the requirement. In their 1989 survey of colleges and universities, Ganschow, Myer, and Roeger (1989) reported that only 25% had a formal petition policy for considering a student's request to substitute courses for or waive the foreign language requirement. However, Driscoll (2003) found that almost 60% of four-year colleges and universities in her more recent survey had a formal petition policy for their foreign language requirement. These findings suggest that most postsecondary institutions are addressing the issue of foreign language course substitutions and waivers and it is likely that the number of students who are substituting or waiving the foreign language requirement is still increasing. Although both 2- and 4-year postsecondary institutions by and large allow students to petition for course substitutions for or waivers from foreign language courses, the criteria that students must satisfy to have their petitions approved varies from institution to institution. Driscoll (2003) found that two thirds of the colleges and universities in her survey required a student to be classified as LD. In a smaller survey of colleges and universities, Smith (2002) reported that all of the respondents required documentation of a learning disability for a student's petition to be considered for approval. Recently, some secondary and postsecondary institutions (as well as individual diagnosticians) have begun to use the Modern Language Aptitude Test (MLAT) (Carroll & Sapon, 1959), a standardized foreign language aptitude test, as a diagnostic tool to determine whether a student should be required to take foreign language courses and to diagnose a for learning a foreign language. Reed and Stansfield (2004) suggested that the use of the MLAT for these purposes may be useful if adequate safeguards are used to protect the testing process and professionals use sound diagnostic judgment. However, in several studies Sparks and his colleagues have found that postsecondary institutions and individual diagnosticians have used the MLAT and its results inappropriately to classify a student as LD and subsequently recommend that the student be granted course substitutions for or waivers from the foreign language requirement (Sparks, Philips, Ganschow, & Javorsky, 1999a, 1999b; Sparks, Philips, & Javorsky, 2002, 2003). …

Obstetrician-gynecologists' decision making about the diagnosis of major depressive disorder and premenstrual dysphoric disorder

Major depressive disorder (MDD) is underdiagnosed and undertreated in ambulatory care settings [1–4] including gynecologic practices [5]. Far less is known about the diagnosis of Premenstrual Dysphoric Disorder (PMDD). Three hundred and thirty-five gynecologists responded to mailed questionnaires that used descriptive scenarios as analogues to clinical cases. Questionnaire recipients were randomly selected to receive either a MDD or PMDD version of the questionnaire. Respondents were less accurate when diagnosing MDD cases (48% accuracy; p = 0.526), than PMDD cases (80% accuracy; p < 0.001), but were significantly more confident about their probability ratings of MDD cases, t = 2.57, p < 0.02. Qualitative analysis suggested that less accurate MDD respondents did not prioritize case data according to DSM-IV criteria, whereas almost all PMDD respondents made use of valid reasoning strategies. Respondents did not take base rates into account when deciding about the probability of either affective disorder. Results imply that gynecologists employ cognitive strategies that result in accurate diagnostic judgments about PMDD, but overconfidence, lack of attention to DSM-IV criteria and base rate neglect could hinder clinical decisions about MDD, and may contribute to underdiagnosis of depression.

The significance of pepsinogen with its subgroup and CA72-4 associate detect applied to early diagnostic and prognosis judgment on gastric cancer

To find out the connection of serum pepsinogen and it's subgroups (PGI, PGII) with CA72-4 to early diagnosis and postoperative recurrence on gastric cancer. RIA was applied to detect the results of serum PGI, PGII and CA72-4 on gastric cancer and other stomach diseases, then the clinic value of associating detection on gastric cancer diagnosis and prognosis judgment were assessed. The serum PG levels of GC patients were significantly lower comparing to those of healthy controls (P < 0.01), apparent changes had taken place on earlier period GC (P < 0.05), and aggressive GC were even lower (P < 0.01). On the earlier period of GC diagnosis, CA72-4 levels were not apparently different to healthy controls (P > 0.05), and aggressive GC were significantly higher (P < 0.01). Compared preoperative with postoperative, the serum PGI and PGII and CA72-4 levels were significantly different (P < 0.01). In the patients underwent total gastrectomy, both of pepsinogen levels were lower than those of subtotal or large partial gastrectomy (P < 0.05). The serum PGI, PGII and CA72-4 levels of patients with recurrence of GC after total gastrectomy were significantly higher than those without. Compared before recurrence patients with after ones, the serum PGI and PGII levels of partial gastrectomy were no apparent difference (P > 0.05), however apparent changes had taken place on CA72-4 levels. The associate detection had even higher specificity (P < 0.01). Apply to detect the serum PG levels on crowds, especially pGI, PGI/II levels decrease, which may be expected to become the index to earlier period GC screening. The associating detection to PG and CA72-4 levels may significantly improve sensitivity and specificity, which have chances to be applied to monitoring to postoperative gastrectomy.

Is JPEG Compression of Videomicroscopic Images Compatible with Telediagnosis? Comparison between Diagnostic Performance and Pattern Recognition on Uncompressed TIFF Images and JPEG Compressed Ones

Early melanoma diagnosis is an important goal for dermatologists. Polarized light systems are increasingly employed for dermatoscopic diagnosis of melanocytic lesions. For the purpose of teledermoscopy, whose importance is increasingly growing for consultation and teaching purposes, it is of utmost importance to establish whether, after compression, polarized light images maintain their informativeness. The aim of our study was to check the effects of compression on melanocytic lesion images acquired by means of a digital videomicroscope on the identification of morphological details of the image and on diagnostic accuracy. A total of 170 50-fold-magnified pigmented skin lesion images, acquired in Tagged Image File Format (TIFF) by a digital videomicroscope, were compressed using Joint Photographic Experts Group (JPEG) algorithms (compression factor 30). Two experts in videomicroscopy evaluated both original and compressed images twice by describing single lesion features and expressing a diagnosis. Reproducibility in the assessment of dermoscopic parameters and observer performance were studied by kappa statistics and Receiver Operating Characteristic (ROC) analysis. Both intra- and interobserver reproducibility in the assessment of morphological details were higher when TIFF images were considered, indicating a better image quality. Nonetheless, there was no significant difference in the diagnostic accuracy between uncompressed images and compressed ones, although the intraobserver reproducibility in the diagnostic judgement was higher for uncompressed images. Despite loss in image details, factor 30 compressed videomicroscopic images enable a good diagnostic accuracy.

Is JPEG Compression of Videomicroscopic Images Compatible with Telediagnosis? Comparison between Diagnostic Performance and Pattern Recognition on Uncompressed TIFF Images and JPEG Compressed Ones

Early melanoma diagnosis is an important goal for dermatologists. Polarized light systems are increasingly employed for dermatoscopic diagnosis of melanocytic lesions. For the purpose of teledermoscopy, whose importance is increasingly growing for consultation and teaching purposes, it is of utmost importance to establish whether, after compression, polarized light images maintain their informativeness. The aim of our study was to check the effects of compression on melanocytic lesion images acquired by means of a digital videomicroscope on the identification of morphological details of the image and on diagnostic accuracy. A total of 170 50-fold-magnified pigmented skin lesion images, acquired in Tagged Image File Format (TIFF) by a digital videomicroscope, were compressed using Joint Photographic Experts Group (JPEG) algorithms (compression factor 30). Two experts in videomicroscopy evaluated both original and compressed images twice by describing single lesion features and expressing a diagnosis. Reproducibility in the assessment of dermoscopic parameters and observer performance were studied by kappa statistics and Receiver Operating Characteristic (ROC) analysis. Both intra- and interobserver reproducibility in the assessment of morphological details were higher when TIFF images were considered, indicating a better image quality. Nonetheless, there was no significant difference in the diagnostic accuracy between uncompressed images and compressed ones, although the intraobserver reproducibility in the diagnostic judgement was higher for uncompressed images. Despite loss in image details, factor 30 compressed videomicroscopic images enable a good diagnostic accuracy.

Predicting the accuracy of a diagnosis of Alzheimer's disease with 99mTc HMPAO single photon emission computed tomography

The current clinical practice of reporting images obtained with single photon emission computed tomography (SPECT) with 99mTc- d,l-hexamethylpropylene amine oxime ( 99mTc HMPAO) images was examined by having 16 experts evaluate the appearance of SPECT images in patients with probable Alzheimer type dementia (ATD), patients with major depressive episode (DSM-IV), and healthy volunteers. The experts rated diagnostic criteria of scan appearance in respect of importance for their individual diagnostic practice. Experts were nuclear medicine specialists, psychiatrists and physicists taking part in a European multi-centre collaborative project. They examined 158 perfusion scans and then the same perfusion scans together with statistical parametric maps (SPMs). The sensitivity of experts’ diagnostic judgments was significantly and negatively correlated with the importance they attributed to reduced regional perfusion in the parietal lobes. A corresponding positive correlation was observed for diagnostic specificity against depressed and healthy volunteers. Similar results were observed with SPMs, where in addition area under the receiver operating characteristic (ROC) curve was significantly reduced with raters’ increased diagnostic reliance on frontal lobe perfusion deficits. Sensitivity was greater with SPM for patients younger than 70 years and with dementia severity. The more importance experts placed on parietal (symmetrical) perfusion deficits, the less sensitive and the more specific their diagnostic judgment was. Using multiple raters in large patient samples may provide a way of identifying successful explicit diagnostic strategies for clinical image analysis.

Dr. Olfson and Colleagues Reply

Back to table of contents Previous article Next article Letter to the EditorFull AccessDr. Olfson and Colleagues ReplyMARK OLFSON, M.D., M.P.H., MARC J. GAMEROFF, Ph.D., PETER S. JENSEN, M.D., and STEVEN C. MARCUS, Ph.D., MARK OLFSONSearch for more papers by this author, M.D., M.P.H., MARC J. GAMEROFFSearch for more papers by this author, Ph.D., PETER S. JENSENSearch for more papers by this author, M.D., and STEVEN C. MARCUSSearch for more papers by this author, Ph.D., New York, N.Y.Published Online:1 May 2004https://doi.org/10.1176/appi.ajp.161.5.932-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Dr. Evans suggests that mental health professionals in the United States and United Kingdom favor diagnosing white children with ADHD and black children with conduct disorder. To support this assertion, he cites our recent finding of a higher rate of treatment of ADHD in white than black youth in the United States and a British epidemiological study that reported a statistically nonsignificant higher rate of conduct disorder in black than white children. The British study also found that across all ethnic groups, conduct disorders were highly comorbid with ADHD, with an odds ratio of 38.43 (95% confidence interval=26.87–54.96). However, bias in routine diagnostic practices cannot be established by analyzing patterns in community prevalence or treatment rates. Such diagnostic biases can be measured only by studying the behavior of mental health professionals in relation to a criterion standard.The possibility of widespread ethnic bias in routine clinical diagnostic practice merits careful scientific study. Such research might involve comparisons of ethnically sensitive independent expert diagnostic assessments (1) with clinical diagnoses in routine care or sampling the diagnostic judgments of mental health professionals with standardized clinical patients or vignettes that systematically vary patient ethnicity (2). In the absence of such research, the politically charged speculation offered by Dr. Evans runs the risk of trivializing what may be an important issue in the delivery of child mental health services.

The diagnostic value of IADL evaluation in the detection of dementia in general practice

It is assumed that general practitioners can make an important contribution to the diagnosis of dementia. One of the used strategies comprises an evaluation of the Instrumental Activities of Daily Living (IADL). There are contradictory data on the value of this strategy. During one month, 21 Flemish general practitioners evaluated the IADL capacities of all subjects older than 65 years with whom they had contact. Subjects with dementia and/or living in a residential home for the elderly were excluded. Housing and living conditions, medication use and IADL were registered. The general practitioner formulated a clinical evaluation. All subjects with an IADL score ≥ 1 and a random sample from the group IADL = 0 underwent a Mini Mental State Examination. Subjects with an IADL score = 4 were referred for neuropsychological and specialist examination. The average age of the 1003 registered subjects was 75.1 years (SD = 6.8). A large majority of them (85%) were totally independent. There was a large discrepancy between the family's and the patient's judgment on the presence of memory problems. There was an inverse correlation between the IADL and MMSE: when the IADL score increased, the MMSE score fell. The diagnostic value of the IADL for the diagnosis of dementia with Camdex-N as a reference standard could not be evaluated because the number of tested subjects was too small. Against the MMSE, sensitivity was 0.81 (SE = 0.03), and specificity was 0.48 (SE = 0.05). The evaluation of the IADL activities had some drawbacks as a detection method for dementia but the use of IADL data may still be clinically valuable in general practice. The correlation between the general practitioner's judgment and that of the specialist was very good. This study showed that the use of the IADL score might change the general practitioner's diagnostic judgment. Furthermore this study confirms the existence of a major threshold for the referral to a specialist of patients with suspected dementia by general practitioners.

Enhancing diagnostic reasoning skills in nurse practitioner students: a teaching tool.

The Advanced Health Assessment course provides an opportunity to focus on critical thinking and diagnostic reasoning skills as students transition to the nurse practitioner role. The authors describe a structured teaching tool designed for faculty to use in facilitating diagnostic reasoning and clinical judgment. This tool gives faculty a format to use in the classroom or online for helping students decide which data to collect and which data are important in developing hypothesis driven differential diagnoses.

Shockingly complex: the difficult road to introducing new ideas to critical care

Resuscitation of critically ill patients with trauma or sepsis continues to challenge clinicians. Early imperatives include diagnostic judgment as to the presenting problem – sepsis or trauma. Subsequently, the clinician decides on the phase of resuscitation required for support – 'ebb' versus 'flow'. Finally, the clinician needs to determine what therapeutic strategies to employ and then judge when resuscitation is complete. Shortcomings of current approaches to determining the adequacy of circulatory resuscitation have prompted the evaluation of new technologies purported to directly assess microcirculatory flow as a clinical endpoint for the adequacy of resuscitation. While early studies are intriguing, this technology requires much more study before it can be considered for widespread adoption by the clinician.

The evidence-based case report: a resource pack for chiropractors

Evidence-based medicine (EBM) is described as ‘‘. . . the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research.’’ More recently, this definition has been updated to incorporate patient values in the decision process. These key elements of evidencebased clinical decisions are depicted in Fig. 1. The overall aim of EBM is to provide the best possible care for the individual patient. The integration of best research evidence, clinical expertise and patient values, allows clinicians and patients to form a ‘‘diagnostic and therapeutic alliance’’ to optimise clinical outcomes and quality of life. As professionals, we should constantly question clinical practice how and why we practice in the way we do and whether we are providing the most effective care for our patients. To do less is to practice as a technician and not as a professional. The need for evidence-based practice has arisen from the rapid advances in medical knowledge and the large number of clinical papers being published. Traditional sources of information such as textbooks rapidly become out of date. Consequently, a disparity develops between diagnostic skills and clinical judgement that increases with experience and dating of academic knowledge resulting in a decline in clinical performance over time. EBM was developed to help bridge this gap between research and practice. Recent advances in database searching and secondary sources of evidence, as well as improved access to them, have made the practice of EBM a more viable option.

Triangulation as a basis for diagnostic judgments

The methodological concept of triangulation is discussed with special reference to the principles and procedures of triangulation as a general basis for diagnostic judgments. It is emphasized that triangulation always requires theoretical considerations. An action‐theory approach is introduced that provides the potential to establish such a concept. The differentiation between triangulation of data, criteria, and participants is explained and examples for the process of triangulation are provided. Finally, design triangulation is proposed to be used in extensive research processes in which large‐N studies, small‐N studies, and single case analysis complement each other.

Does choosing a treatment depend on making a diagnosis? US and French physicians' decision making about acute otitis media.

The classic sequential processing model of clinical decision making-in which the treatment choice follows and depends on the diagnostic judgment-may in some cases be replaced by a processing model in which the treatment choice depends on an independent assessment of the diagnostic and other cues. The aim of this study was to determine which processing model would better describe physicians' treatment choices in a simulated clinical task. Seventy-five US and French primary care physicians were presented twice, in a different order, with the same set of 46 scenarios of 15-month-old children suspected of having acute otitis media (AOM). They rated in one set the probability of AOM and in the other set whether they would treat the child with antibiotics (and how confident they felt in their decision). Linear regression analyses revealed the individuals' 2 judgment policies. Hierarchical discriminant analysis was used to analyze the variance explained in the treatment choice by, 1st, the diagnostic judgment, 2nd, the cues specific to treatment, and 3rd, the cues specific to diagnosis. Even when choosing treatment, the participants placed greatest weight on diagnostic cues, especially the ear findings. Only 28% used the cues that reflected parental issues. For 36%, the diagnostic cues had an effect on the treatment choice independent of the effect (if any) of the diagnostic judgment. In deciding how to treat AOM, the majority of the participating US and French primary care physicians followed the classic sequential processing model, but a substantial minority used instead an independent processing model.

Chronic Illness and Educational Equity: The Politics of Visibility

By using the university's disability policy, chronically ill women become visible in ways that subsequently determine aspects of their undergraduate and graduate careers. This constitutes an exercise of power normally understood as the university acting in the interests of students with disabilities. Using an institutional ethnographic approach, this inquiry starts with the embodied experience of chronically ill women pursuing post-secondary education in order to shed light on the broader social processes that produce systemic inequities for people with disabilities. Specifically, I contend that the requirement that chronically ill students identify themselves as disabled in the context of the university, subjects them to normative, prognostic, diagnostic, and other judgments and assessments that may disorganize their future student and career opportunities.

Determinants of diagnostic prototypicality judgments of the personality disorders.

We evaluated the impact of three factors that have been suggested to be important determinants of the diagnostic process pertaining to personality disorders: (a) the number of features representative of a personality disorder category; (b) the extent to which those features are typical of the category, and (c) the dominance or proportion of category features to the total number of features. Thirty-two clinical psychologists evaluated 12 profiles of hypothetical patients in which these factors were varied factorially. The results revealed strong effects of typicality and dominance, but no effects for number. Implications for the assessment and classification of personality disorders are discussed.

Tubal pelvic damage: Prediction and prognosis

Tubal pelvic damage is a common cause of infertility, and laparoscopy is the accepted gold standard for its diagnosis. However, laparoscopy is both costly and invasive. Chlamydia is now recognized as the most common cause of tubal pelvic damage. In contrast to laparoscopy, evidence of past chlamydial infection using serology is readily avilable, and the test is simple and quick to perform. As such, serology can be used as a screening test in infertile women. It is accepted that screening tests may have higher margins of error and may be less accurate than diagnostic tests. Screening is most valuable when detecting a disease for which the treatment is more effective when undertaken at the earliest opportunity. Because there are justified constraints to the indiscriminate use of laparoscopy, there is a need to minimize the number of patients who do not have disease (false positives) who are subjected to this diagnostic investigation. An appropriate Chlamydia antibody titre that would distinguish women at risk of tubal pelvic damage should be determined using diagnostic test analysis and clinical judgement. Identification by serology of women who are likely to have damage would enable these women to undergo a diagnostic test such as laparoscopy sooner, allowing treatment to be provided earlier. However, the severity of tubal pelvic damage varies, and the need to distinguish women with a favourable or unfavourable prognosis after treatment using a simple classification system is discussed.

ICSD diagnostic criteria for narcolepsy: interobserver reliability. Intemational Classification of Sleep Disorders.

To estimate the reliability of the diagnosis of narcolepsy after clinical interview and polysomnographic evaluation among sleep medicine doctors, before and after training in application of the International Classification of Sleep Disorders (ICSD). Videotaped semi-structured interviews of 10 patients complaining of daytime sleepiness of different etiologies. Questions referred to ICSD criteria for narcolepsy. A further series of 10 cases of narcolepsy without cataplexy were simulated, with at least a random one to three of the ICSD polysomnographic criteria at pathological levels. Seventeen doctors were required to classify each videotaped case as "ascertained," "possible," or "excluded" narcolepsy, in two sessions: one before and one after discussion of ICSD criteria. The observers were invited to confirm or exclude the diagnosis of narcolepsy in the 10 simulated cases, according to the given polysomnographic findings, before and after an agreed proposal of the interpretation of ICSD polysomnographic criteria. Interobserver reliability was calculated using Kappa statistics. N/A. Interobserver reliability of clinical judgement improved from "substantial" at baseline (Kappa 0.61) to "almost perfect" after training (Kappa 0.95). Interobserver reliability of polysomnographic findings was "fair" at baseline (Kappa 0.24), unanimous after the proposed interpretation of ICSD polysomnographic criteria. Baseline reliability of diagnostic judgement in suspected narcolepsy was found satisfactory among Italian sleep medicine doctors. Educational training, based on discussion of ICSD criteria, further improved agreement. Diagnosis based on polysomnographic findings, not reliable at baseline, needed a strict interpretation of ICSD criteria to attain standardization.

Spinning out of control

Although the term spin is generally used to imply a rapid rotation or twirling of an object, it was Melville who added new meaning to the word when he referred to “fellows who spin interminable yarns.” The year 2000 saw the art of spinning brought to new heights during the election campaign and the postelection recount. It was not unusual to hear a candidate replying to a question with an answer that was totally unrelated to what was being asked or to listen to advocates commenting on the same issue providing viewpoints that were diametrically opposite. One might expect such situations in the political arena, but spin has insidiously invaded many other aspects of our personal and professional lives, often without our actually being aware of what is occurring. Although spin is sometimes dismissed as simple euphemism for lying, it is actually more subtle. Michael Kinsley has described spinning as an indifference to the truth. It involves describing a reality that suits one's purpose; whether it resembles true reality does not appear to be an issue. It also involves not being concerned about inconsistency between what is said at one time or another. Spinning starts with the conclusion that one wishes to reach and then coming up with an argument to support it. We have come to expect such behavior from politicians, and thus we have generally learned to filter out the truth from the distortion in these situations. However, we may not be as adept at doing this in other circumstances. A good example is in advertising. Despite the emphasis on truth in advertising, marketing is but another term for spin. We see this daily in the print media as well as on television, where manufacturers attempt to entice the public into purchasing their products with images of exotic venues, flashy automobiles, macho men, and beautiful women. Spin has even spread to the drug industry, with direct advertising to the public in an attempt to encourage viewers to influence their doctors to prescribe certain medications for their medical problems. As health professionals, we may be able to recognize such ploys, but are we just as astute when it comes to advertising directed at us? We have an duty to our patients to view such material critically and to look beyond the claims for proof of efficacy and true advantages over currently established therapeutic approaches before being enticed to make a change. Although we are often unaware of the fact, our patients sometimes also use spin in an attempt to influence our diagnostic judgment or affect our therapeutic decisions. This may be reflected in an exaggeration of symptoms, the omission or denial of past events that may have contributed to their condition, or the inclusion of complaints that have no logical physiologic or anatomic explanation. Such situations are frequently encountered in patients with chronic pain, especially those who are seeking analgesic and narcotic drugs. The challenge is to separate fact from fiction so that these patients receive the appropriate treatment for both their physical and emotional problems. Finally, we run the risk of being bombarded with spin from our professional colleagues. Although this can occur in the interpretation of the findings in published clinical studies, having the data permits one to arrive at his or her own conclusions. However, when data is not provided, or it is based strictly on the author's subjective evaluation of the results, the task may be more difficult. At least the information is in printed form and can be critically reviewed. This is not possible when one listens to a lecture and the data is rapidly flashed on the screen or a statement is made without any substantiation other than the enthusiastic endorsement of the speaker. This can be spin in its ultimate form. We have an obligation to practice evidence-based treatment, but lecturers have an even greater obligation not to use their professional stature to spin the truth in an attempt to support their position. As professionals, we have an ethical responsible to our patients and our colleagues to be absolutely honest in our interactions with them. We may not be able to control the media, but we can certainly keep our professional relationships from spinning out of control. As an old Swedish proverb states, “It is better to suffer from the truth than to be rewarded for a lie.”

La relación médico paciente: entre la supremacía del signo y la exclusión del síntoma

El texto aborda un punto central del acto médico, como es el de la construcción de un juicio diagnóstico a partir de la puesta en acción de la propedéutica médica: reconocimiento de signos y síntomas. No obstante, en nuestro trabajo al lado de los médicos, hemos observado cómo cada vez más hay un intento de objetivación en el acto, que privilegia al signo, en tanto se supone que no engaña, carácter que sí se le atribuye al síntoma desde tiempos de Hipócrates. Para demostrar esto se realiza inicialmente un breve recorrido histórico por la construcción del signo médico, así como por un paralelo entre éste y el signo lingüístico, para arribar a lo que denominamos los desencuentros con el paciente. Allí intentamos señalar cómo el ser del paciente que podría escucharse en el síntoma es excluido, en favor a la observación del signo.