Technology helps us to be more human

Paco Miralles

"Learning to read is the most important thing that has happened to me in life," acknowledged Vargas Llosa in his speech at the reception of the Nobel Prize. I share his discernment, although I have had some more important achievements. This task is something inherent to the doctor, one of the weapons that help the indispensable humanistic aspect of medicine.

30% of digestive endoscopies have questionable indications

@varelalaf

In an article in the series "Less is More" by Gastroenterology, three digestiologists, Shaheen, Fennerty and Bergman, after an extensive review of the literature, conclude that 30% of digestive endoscopies have questionable indications. According to the authors, many clinical practice guidelines stimulate the exaggerated consumption of these tests in clinical situations of doubtful indication, such as recommendations for the follow-up of low-risk patients of Barrett's disease (oesophageal reflux), which they say they are "carefully misleading." On the other hand, the prevailing cancer phobia places a lot of pressure on the examination rooms, which are permanently overwhelmed, not only by inappropriate requests but by follow-up guidelines that anticipate the requirements demanded by the clinical practice guidelines themselves.

Physical examination is reclaimed

Acute vestibular syndrome, characterized by dizziness, nausea and vomiting, is often due to a local neuritis of the inner ear, despite the fact that a doctor cannot overlook that with these symptoms he or she must first rule out the vertebrobasilar stroke, a less common aetiology, but obviously a lot more serious. I chose this health condition because the neurologist David Newman-Toker from Johns Hopkins (and the team) have systematized HINTS (Head Impuls, Nystagmus and a Test Skew), an examination that requires nothing more than some basic neurologist’ tasks: a) the patient is asked to move his head while focusing at the examiner’s nose; b) the nystagmus is measured on lateral gaze, and c) one of the patient's eyes is covered with the hand while the other eye will focus at the examiner’s  nose and then the other eye is suddenly uncovered. On the understanding that family physicians and emergency room doctors know how to do this (and they probably do) the essential neurological examination before a persistent vestibular syndrome, should be aware that the study published by the team Newman-Toker in the Stroke journal states that HINTS has shown 100% sensitivity and 96% specificity so that the doctor can rule out the vertebrobasilar stroke in people with acute vestibular syndrome, values exceeding those of nuclear magnetic resonance.

Hunting zebras in Texas or why doctors order so many tests

Bayes’s theorem estimates the probability of an event occurring if another one occurred before. If we hear thunder, it’s very likely that soon it will start to rain. However, biomedicine is more interested by the inverse probabilistic formulation because often when an observation is made we look for the cause: "If, for example, you find yourself on a ranch in Texas and hear the sound of trotting horses, what is the probability that a herd of zebras will approach? ”Dr. Saurabh Jha, radiologist, blogger and contributor to the BMJ, says that we hunted zebras in Texas for long enough. "The clinical reasoning of many doctors today - explains Dr. Jha - forgot the Bayesian thinking and embraced instead the thesis that it’s better to manage a false positive than a false negative."

When, in the second decade of the last century, he was asked why he wanted to climb Everest, George Mallory, an English mountaineer, replied that it’s because the mountain was there. According to Dr. Jha, many doctors feel the same as Mallory: they ask for tests because they can. In his article in the BMJ, the radiologist explained the case of a patient of Dr. Watson, a well read doctor emerged from a refined education who pays a lot of attention to detail but lacks the deductive ability of the famous Sherlock Holmes’ assistant. If you have a chance to read the letter, you will see how for the study of this case, nothing seems elementary to Dr. Watson, to the extent that for every horse he sees an opportunity for a zebra hunt. "Zebras are intellectually exciting," Dr. Jha ends up saying.