Becoming a Consummate Clinician

Ary L. Goldberger, MD, is Director of the Rey Laboratory and Professor of Medicine at the Harvard Medical School. He is Program Director of the Research Resource for Complex Physiologic Signals, which is funded by the National Institute of Biomedical Imaging and Bioengineering and the National Institute of General Medical Sciences of the National Institutes of Health. He is also a core faculty member of the Wyss Institute for Biologically Inspired Engineering at Harvard. Zachary D. Goldberger, MD, MS,is an Assistant Professor in the Department of Internal Medicine in the Division of Cardiology at Harborview Medical Center/University of Washington Medical School, in Seattle, WA. He received his medical degree from Yale University School of Medicine and then completed his Internal Medicine training at the University of Washington. He completed a fellowship in cardiovascular medicine at the University of Michigan, where he was a 2010-2012 Robert Wood Johnson Foundation Clinical Scholar.

Preface ix

Acknowledgments xi

INTRODUCTION: SURVIVING AND THRIVING IN WARD WORLD 1

PART 1 MEDICAL MUSTS AND MUST-NOTS: SIX ESSENTIALS OF WARD WORLD

1 HOW (NOT) TO PRESENT A PATIENT HISTORY 13

2 REEXAMINING THE PHYSICAL EXAM 37

3 HOW (NOT) TO ORDER AND PRESENT LAB TESTS 67

4 SEEING IS (ALMOST) BELIEVING: THE IMPORTANCE OF REVIEWING DATA 81

5 "WORSTS FIRST": HOW TO FRAME A DIFFERENTIAL DIAGNOSIS 93

6 CLINICAL QUERIES: ASKING THE 3½ KEY QUESTIONS 103

PART 2 MEDICAL MASTERIES

7 E = MC3: ERROR REDUCTION EQUALS MOTIVATION TIMES COMMUNICATION TO THE POWER OF 3 115

8 EVIDENCE-BASED MEDICINE: WHAT AND WHERE IS THE EVIDENCE? 131

9 CAUTION! DANGEROUS BIOMEDICAL SEMANTICS AT WORK 145

10 SOME SECOND OPINIONS: OUTLIERS, HOOFBEATS, AND SUTTON’S (FLAWED) LAW 165

11 A SIXFOLD PATH: FROM DATA TO KNOWLEDGE TO UNDERSTANDING 173

12 WHAT IS DISEASE? WHAT IS HEALTH? 181

Bibliography and Notes 195

Index 203