Internal medicine: Difference between revisions

Determining which pieces of information are most important to the next phase of the diagnostic process is of vital importance.<ref name=":1" /><ref>{{Cite journal |last1=Hegedus |first1=Eric J. |last2=Goode |first2=Adam P. |last3=Cook |first3=Chad E. |last4=Michener |first4=Lori |last5=Myer |first5=Cortney A. |last6=Myer |first6=Daniel M. |last7=Wright |first7=Alexis A. |date=November 2012 |title=Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests |url=https://pubmed.ncbi.nlm.nih.gov/22773322 |journal=British Journal of Sports Medicine |volume=46 |issue=14 |pages=964–978 |doi=10.1136/bjsports-2012-091066 |issn=1473-0480 |pmid=22773322|s2cid=2373599 |doi-access=free }}</ref> It is during this stage that clinical bias like anchoring or premature closure may be introduced.<ref>{{Cite journal |last1=Saposnik |first1=Gustavo |last2=Redelmeier |first2=Donald |last3=Ruff |first3=Christian C. |last4=Tobler |first4=Philippe N. |date=2016-11-03 |title=Cognitive biases associated with medical decisions: a systematic review |journal=BMC Medical Informatics and Decision Making |volume=16 |issue=1 |pages=138 |doi=10.1186/s12911-016-0377-1 |issn=1472-6947 |pmc=5093937 |pmid=27809908}}</ref> Once key findings are determined, they are compared to profiles of possible diseases.  These profiles include findings that are typically associated with the disease and are based on the likelihood that someone with the disease has a particular symptom.  A list of potential diagnoses is termed the “differential diagnosis” for the patient and is typically ordered from most likely to least likely, with special attention given to those conditions that have dire consequences for the patient if they were missed.<ref>{{Cite journal |last1=Weingart |first1=C. |last2=Schneider |first2=H.-J. |last3=Sieber |first3=C. C. |date=September 2017 |title=[Syncope, falls and vertigo] |url=https://pubmed.ncbi.nlm.nih.gov/28717918 |journal=Der Internist |volume=58 |issue=9 |pages=916–924 |doi=10.1007/s00108-017-0292-2 |issn=1432-1289 |pmid=28717918}}</ref><ref>{{Cite journal |last1=Kwok |first1=Chun Shing |last2=Bennett |first2=Sadie |last3=Azam |first3=Ziyad |last4=Welsh |first4=Victoria |last5=Potluri |first5=Rahul |last6=Loke |first6=Yoon K. |last7=Mallen |first7=Christian D. |date=2021-09-01 |title=Misdiagnosis of Acute Myocardial Infarction: A Systematic Review of the Literature |url=https://pubmed.ncbi.nlm.nih.gov/33606411 |journal=Critical Pathways in Cardiology |volume=20 |issue=3 |pages=155–162 |doi=10.1097/HPC.0000000000000256 |issn=1535-2811 |pmid=33606411|s2cid=231961318 }}</ref> Epidemiology and endemic conditions are also considered in creating and evaluating the list of diagnoses.<ref>{{Cite journal |last1=Fusco |first1=Francesco Maria |last2=Pisapia |first2=Raffaella |last3=Nardiello |first3=Salvatore |last4=Cicala |first4=Stefano Domenico |last5=Gaeta |first5=Giovanni Battista |last6=Brancaccio |first6=Giuseppina |date=2019-07-22 |title=Fever of unknown origin (FUO): which are the factors influencing the final diagnosis? A 2005-2015 systematic review |journal=BMC Infectious Diseases |volume=19 |issue=1 |pages=653 |doi=10.1186/s12879-019-4285-8 |issn=1471-2334 |pmc=6647059 |pmid=31331269}}</ref>

The list is dynamic and changes as the physician obtains additional information that makes a condition more (“rule-in”) or less (“rule-out”) likely based on the disease profile.<ref>{{Cite journal |last1=Knuuti |first1=Juhani |last2=Ballo |first2=Haitham |last3=Juarez-Orozco |first3=Luis Eduardo |last4=Saraste |first4=Antti |last5=Kolh |first5=Philippe |last6=Rutjes |first6=Anne Wilhelmina Saskia |last7=Jüni |first7=Peter |last8=Windecker |first8=Stephan |last9=Bax |first9=Jeroen J. |last10=Wijns |first10=William |date=2018-09-14 |title=The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability |url=https://pubmed.ncbi.nlm.nih.gov/29850808 |journal=European Heart Journal |volume=39 |issue=35 |pages=3322–3330 |doi=10.1093/eurheartj/ehy267 |issn=1522-9645 |pmid=29850808}}</ref> <ref>{{Cite journal |last1=Westwood |first1=Marie |last2=Ramaekers |first2=Bram |last3=Grimm |first3=Sabine |last4=Worthy |first4=Gill |last5=Fayter |first5=Debra |last6=Armstrong |first6=Nigel |last7=Buksnys |first7=Titas |last8=Ross |first8=Janine |last9=Joore |first9=Manuela |last10=Kleijnen |first10=Jos |date=May 2021 |title=High-sensitivity troponin assays for early rule-out of acute myocardial infarction in people with acute chest pain: a systematic review and economic evaluation |journal=Health Technology Assessment |volume=25 |issue=33 |pages=1–276 |doi=10.3310/hta25330 |issn=2046-4924 |pmc=8200931 |pmid=34061019}}</ref>  The list is used to determine what information will be acquired next, including which diagnostic test or imaging modality to order.  The selection of tests is also based on the physician’s knowledge of the [[Sensitivity and specificity|specificity and sensitivity]] of a particular test.<ref>{{Cite journal |last1=Hegedus |first1=E. J. |last2=Goode |first2=A. |last3=Campbell |first3=S. |last4=Morin |first4=A. |last5=Tamaddoni |first5=M. |last6=Moorman |first6=C. T. |last7=Cook |first7=C. |date=February 2008 |title=Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests |url=https://pubmed.ncbi.nlm.nih.gov/17720798 |journal=British Journal of Sports Medicine |volume=42 |issue=2 |pages=80–92; discussion 92 |doi=10.1136/bjsm.2007.038406 |issn=1473-0480 |pmid=17720798|s2cid=9717602 |doi-access=free }}</ref><ref>{{Cite journal |last1=Wacker |first1=Christina |last2=Prkno |first2=Anna |last3=Brunkhorst |first3=Frank M. |last4=Schlattmann |first4=Peter |date=May 2013 |title=Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis |url=https://pubmed.ncbi.nlm.nih.gov/23375419 |journal=The Lancet. Infectious Diseases |volume=13 |issue=5 |pages=426–435 |doi=10.1016/S1473-3099(12)70323-7 |issn=1474-4457 |pmid=23375419}}</ref><ref>{{Cite journal |last1=Garcia-Casal |first1=Maria Nieves |last2=Pasricha |first2=Sant-Rayn |last3=Martinez |first3=Ricardo X. |last4=Lopez-Perez |first4=Lucero |last5=Peña-Rosas |first5=Juan Pablo |date=2021-05-24 |title=Serum or plasma ferritin concentration as an index of iron deficiency and overload |journal=The Cochrane Database of Systematic Reviews |volume=2021 |issue=5 |pages=CD011817 |doi=10.1002/14651858.CD011817.pub2 |issn=1469-493X |pmc=8142307 |pmid=34028001}}</ref>

Treatment modalities generally include both pharmacological and non-pharmacological, depending on the primary diagnosis.<ref>{{Cite journal |last1=Gay |first1=C. |last2=Chabaud |first2=A. |last3=Guilley |first3=E. |last4=Coudeyre |first4=E. |date=June 2016 |title=Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review |url=https://pubmed.ncbi.nlm.nih.gov/27053003 |journal=Annals of Physical and Rehabilitation Medicine |volume=59 |issue=3 |pages=174–183 |doi=10.1016/j.rehab.2016.02.005 |issn=1877-0665 |pmid=27053003|doi-access=free }}</ref><ref>{{Cite journal |last1=Fu |first1=Jinming |last2=Liu |first2=Yupeng |last3=Zhang |first3=Lei |last4=Zhou |first4=Lu |last5=Li |first5=Dapeng |last6=Quan |first6=Hude |last7=Zhu |first7=Lin |last8=Hu |first8=Fulan |last9=Li |first9=Xia |last10=Meng |first10=Shuhan |last11=Yan |first11=Ran |last12=Zhao |first12=Suhua |last13=Onwuka |first13=Justina Ucheojor |last14=Yang |first14=Baofeng |last15=Sun |first15=Dianjun |date=2020-10-20 |title=Nonpharmacologic Interventions for Reducing Blood Pressure in Adults With Prehypertension to Established Hypertension |journal=Journal of the American Heart Association |volume=9 |issue=19 |pages=e016804 |doi=10.1161/JAHA.120.016804 |issn=2047-9980 |pmc=7792371 |pmid=32975166}}</ref> <ref>{{Cite journal |last1=Malesker |first1=Mark A. |last2=Callahan-Lyon |first2=Priscilla |last3=Ireland |first3=Belinda |last4=Irwin |first4=Richard S. |last5=CHEST Expert Cough Panel |date=November 2017 |title=Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report |journal=Chest |volume=152 |issue=5 |pages=1021–1037 |doi=10.1016/j.chest.2017.08.009 |issn=1931-3543 |pmc=6026258 |pmid=28837801}}</ref><ref name=":2">{{Cite journal |last1=Viniegra Domínguez |first1=M. Adela |last2=Parellada Esquius |first2=Neus |last3=Miranda de Moraes Ribeiro |first3=Rafaela |last4=Parellada Pérez |first4=Laura Mar |last5=Planas Olives |first5=Carme |last6=Momblan Trejo |first6=Cristina |date=June 2015 |title=[An integral approach to insomnia in primary care: Non-pharmacological and phytotherapy measures compared to standard treatment] |journal=Atencion Primaria |volume=47 |issue=6 |pages=351–358 |doi=10.1016/j.aprim.2014.07.009 |issn=1578-1275 |pmc=6983700 |pmid=25443769}}</ref><ref>{{Cite journal |last1=Leite |first1=Renata Giacomini Oliveira Ferreira |last2=Banzato |first2=Luísa Rocco |last3=Galendi |first3=Julia Simões Corrêa |last4=Mendes |first4=Adriana Lucia |last5=Bolfi |first5=Fernanda |last6=Veroniki |first6=Areti Angeliki |last7=Thabane |first7=Lehana |last8=Nunes-Nogueira |first8=Vania Dos Santos |date=2020-01-12 |title=Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis |journal=BMJ Open |volume=10 |issue=1 |pages=e034481 |doi=10.1136/bmjopen-2019-034481 |issn=2044-6055 |pmc=7045081 |pmid=31932394}}</ref> Additional treatment options include referral to specialist care including physical therapy and rehabilitation.<ref>{{Cite journal |date=September 1999 |title=Guidelines for referral and management of systemic lupus erythematosus in adults. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines |url=https://pubmed.ncbi.nlm.nih.gov/10513791 |journal=Arthritis and Rheumatism |volume=42 |issue=9 |pages=1785–1796 |doi=10.1002/1529-0131(199909)42:9<1785::AID-ANR1>3.0.CO;2-# |issn=0004-3591 |pmid=10513791}}</ref>  Treatment recommendations differ in the acute inpatient and outpatient settings.<ref name=":2" /><ref>{{Cite journal |last1=A |first1=Pérez |last2=A |first2=Ramos |last3=G |first3=Carreras |date=Jan–Feb 2020 |title=Insulin Therapy in Hospitalized Patients |url=https://pubmed.ncbi.nlm.nih.gov/31833876/ |journal=American Journal of Therapeutics |language=en |volume=27 |issue=1 |pages=e71–e78 |doi=10.1097/MJT.0000000000001078 |issn=1536-3686 |pmid=31833876|s2cid=209340414 }}</ref> Continuity of care and long-term follow-up is crucial in successful patient outcomes.<ref>{{Cite journal |last1=Jackson |first1=Claire |last2=Ball |first2=Lauren |date=October 2018 |title=Continuity of care: Vital, but how do we measure and promote it? |url=https://pubmed.ncbi.nlm.nih.gov/31195766 |journal=Australian Journal of General Practice |volume=47 |issue=10 |pages=662–664 |doi=10.31128/AJGP-05-18-4568 |issn=2208-7958 |pmid=31195766|s2cid=169207062 |doi-access=free }}</ref><ref>{{Cite journal |last1=Kripalani |first1=Sunil |last2=LeFevre |first2=Frank |last3=Phillips |first3=Christopher O. |last4=Williams |first4=Mark V. |last5=Basaviah |first5=Preetha |last6=Baker |first6=David W. |date=2007-02-28 |title=Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care |url=https://pubmed.ncbi.nlm.nih.gov/17327525 |journal=JAMA |volume=297 |issue=8 |pages=831–841 |doi=10.1001/jama.297.8.831 |issn=1538-3598 |pmid=17327525}}</ref><ref>{{Cite journal |last1=Goodwin |first1=James S. |last2=Li |first2=Shuang |last3=Hommel |first3=Erin |last4=Nattinger |first4=Ann B. |last5=Kuo |first5=Yong-Fang |last6=Raji |first6=Mukaila |date=2021-08-02 |title=Association of Inpatient Continuity of Care With Complications and Length of Stay Among Hospitalized Medicare Enrollees |journal=JAMA Network Open |volume=4 |issue=8 |pages=e2120622 |doi=10.1001/jamanetworkopen.2021.20622 |issn=2574-3805 |pmc=9026593 |pmid=34383060}}</ref>

Training the next generation of internists is an important part of the profession.  As mentioned above, post-graduate medical education is provided by licensed physicians as part of accredited education programs that are usually affiliated with teaching hospitals.<ref>{{Cite journal |last1=Bowen |first1=Judith L. |last2=Salerno |first2=Stephen M. |last3=Chamberlain |first3=John K. |last4=Eckstrom |first4=Elizabeth |last5=Chen |first5=Helen L. |last6=Brandenburg |first6=Suzanne |date=December 2005 |title=Changing habits of practice. Transforming internal medicine residency education in ambulatory settings |journal=Journal of General Internal Medicine |volume=20 |issue=12 |pages=1181–1187 |doi=10.1111/j.1525-1497.2005.0248.x |issn=1525-1497 |pmc=1490278 |pmid=16423112}}</ref> Studies show that there are no differences in patient outcomes in teaching versus non-teaching facilities.<ref>{{Cite journal |last1=Au |first1=Anita G. |last2=Padwal |first2=Raj S. |last3=Majumdar |first3=Sumit R. |last4=McAlister |first4=Finlay A. |date=March 2014 |title=Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis |url=https://pubmed.ncbi.nlm.nih.gov/24448044 |journal=Academic Medicine: Journal of the Association of American Medical Colleges |volume=89 |issue=3 |pages=517–523 |doi=10.1097/ACM.0000000000000154 |issn=1938-808X |pmid=24448044|s2cid=44730113 |doi-access=free }}</ref> Medical research is an important part of most post-graduate education programs, and many licensed physicians continue to be involved in research activities after completing post-graduate training.<ref>{{Cite journal |last=Levi |first=M. |date=June 2010 |title=Abundance of research talent in internal medicine |url=https://pubmed.ncbi.nlm.nih.gov/20558852 |journal=The Netherlands Journal of Medicine |volume=68 |issue=6 |pages=234–235 |issn=1872-9061 |pmid=20558852}}</ref><ref>{{Cite journal |last1=Ng |first1=Ercan-Fang |last2=Ma |first2=Mahmoud |last3=C |first3=Cottrell |last4=Jp |first4=Campbell |last5=Dm |first5=MacDonald |last6=T |first6=Arayssi |last7=Dc |first7=Rockey |date=January 2021 |title=Best Practices in Resident Research- A National Survey of High Functioning Internal Medicine Residency Programs in Resident Research in USA |url=https://pubmed.ncbi.nlm.nih.gov/33288205/ |journal=The American Journal of the Medical Sciences |language=en |volume=361 |issue=1 |pages=23–29 |doi=10.1016/j.amjms.2020.08.004 |issn=1538-2990 |pmid=33288205|s2cid=225377201 }}</ref>

Providing treatment including prescribing medications based on remote information gathering without a proper established relationship is not accepted as good practice with few exceptions.<ref>{{Cite journal |date=2002-06-01 |title=Model Guidelines for the Appropriate Use of the Internet in Medical Practice |url=http://dx.doi.org/10.30770/2572-1852-88.2.81 |journal=Journal of Medical Regulation |volume=88 |issue=2 |pages=81–87 |doi=10.30770/2572-1852-88.2.81 |s2cid=244874327 |issn=2572-1852|doi-access=free }}</ref> These exceptions include cross-coverage within a practice and certain public health urgent or emergent issues.<ref name=":3" />