Sobre la naturaleza del conocimiento médico y su enseñanza (Parte I) / About the nature of medical knowledge and teaching in the field (Part one)

Introducción: En la actualidad persiste una discusión de larga data en cuanto al grado de especificidad de la educación médica en relación con la educación general. Se han postulado una serie de supuestos educativos propios que confieren características distintivas a la enseñanza de esta profesión. Tales peculiaridades, en el ámbito de la docencia, tienen sus raíces en la propia naturaleza del conocimiento médico y su práctica. Objetivo: Exponer la naturaleza del conocimiento médico y las especificidades de su enseñanza. Posicionamiento del autor: La formación del docente de medicina, con una perspectiva filosófica basada en la crítica de la experiencia y con enfoques epistemológicos de fondo, es una de las áreas críticas que debe recibir atención. Los saberes de carácter metacognitivo, en relación con la naturaleza del conocimiento médico y su enseñanza, deben formar parte tanto del conocimiento de los profesores de medicina como de los propios estudiantes. Conclusiones: La atención clínica de pacientes individuales representa la actividad más característica de la profesión médica. El proceso de diagnóstico constituye la piedra angular del razonamiento clínico. La autoexplicación, la reflexión estructurada, y las oportunidades de actividad clínica constituyen los fundamentos de una eficiente educación médica(AU)

Introduction: A long-standing discussion is still held nowadays concerning the degree of specificity of medical education with respect to general education. A series of educational assumptions have been postulated that confer distinctive characteristics to the teaching of the medical profession. In the field of teaching, such peculiarities are rooted in the very nature of medical knowledge and its practice. Objective: To expose the nature of medical knowledge and the specificities of teaching in the field. Author's position: The training of medical professors, with a philosophical perspective based on the critique of experience and epistemological approaches, is one of the critical areas that should receive attention. Knowledge of a metacognitive nature, in relation to the nature of medical knowledge and teaching in the field, should be part of both the knowledge of medical professors and students themselves. Conclusions: Clinical care of individual patients is an activity inherent to the medical profession. The diagnostic process is the cornerstone of clinical reasoning. Self-explanation, structured reflection and opportunities for clinical activity, are the foundations of efficient medical education(AU)

La tecnología como amenaza creciente a la relación médico-paciente y al método clínico / Technology as a growing threat to the doctor-patient relationship and the clinical method

RESUMEN El avance de las ciencias médicas en la segunda mitad del siglo XX se ha debido a progresos de la terapéutica, las ciencias básicas y la tecnología aplicada al diagnóstico. El objetivo del estudio es ofrecer una valoración del papel que juega el método clínico en la práctica médica. El método científico y clínico, son una unidad inseparable y funcionan en plena armonía. El método clínico es una guía de trabajo aplicable al trabajo médico, con el objetivo de llegar a un diagnóstico contextualizado de la enfermedad que afecta a un individuo. La tecnología no sustituye al método clínico y el deterioro de la relación médico-paciente, la subvaloración del interrogatorio, del examen físico y la sobrevaloración de la tecnología son los aspectos que más afectan su uso y correcta aplicación en la práctica médica(AU)

ABSTRACT The advancement of medical sciences in the second half of the 20th century has been due to advances in therapeutics, basic sciences, and technology applied to diagnosis. The objective of the study is to offer an assessment of the role that the clinical method plays in medical practice. The scientific and clinical method are an inseparable unit and work in full harmony. The clinical method is a work guide applicable to medical work, with the aim of reaching a contextualized diagnosis of the disease that affects an individual. Technology does not replace the clinical method and the deterioration of the doctor-patient relationship, the undervaluation of interrogation, physical examination and the overvaluation of technology are the aspects that most affect its use and correct application in medical practice(AU)

Costo del proceso diagnóstico del cáncer de mama en las Unidades de Medicina Familiar del Instituto Mexicano del Seguro Social, Querétaro, México / Cost of the diagnostic process for breast cancer in the Family Medicine Units of the Mexican Social Security Institute

Objetivo: determinar el costo del proceso diagnóstico del cáncer de mama. Métodos: estudio de costos, en mujeres de 40 años y más, de enero a diciembre del 2010 de las unidades de medicina familiar del Instituto Mexicano del Seguro Social. La muestra se calculó con la fórmula de promedios para población infinita para un total de 245 mujeres. El costo se estimó mediante la técnica de tiempos y movimientos y consulta de expertos; el costo por uso de intervención se calculó con el uso promedio por intervención multiplicado por el costo unitario del mismo. El costo total del proceso diagnóstico se obtuvo de la suma de los costos de cada uno de las intervenciones. El plan de análisis incluyó promedios, porcentajes e intervalos de confianza. Resultados: el costo promedio del proceso diagnóstico fue de $852,45. Conclusión: el proceso diagnóstico de cáncer de mama incluye tamizaje y casos confirmados. El costo del proceso diagnóstico es relativamente bajo ofreciendo mejores perspectivas para el paciente y el sistema de salud.

Objective: to determine the cost of the diagnostic process for breast cancer. Methods: costs were calculated, in women 40 years and older, from January to December 2010 of the Family Medicine Units of the Mexican Social Security Institute. The sample was calculated with the formula for infinite population averages for a total of 245 women. The cost was estimated by time and motion technique and expert consultation, the intervention cost was calculated using the average usage per intervention multiplied by the unit cost thereof. The total cost of the diagnostic process was obtained from the sum of the costs of each of the interventions. The analysis plan included means, percentages and confidence interval. Results: the average cost of the diagnostic process was $852.45. Conclusions: the diagnostic process for breast cancer include screening and confirmatory cases. The cost of the diagnostic process is low, offers better prospects for the patient and the health system.

Diagnosis and treatment of chronic cough with combined cause-oriented diagnostic process and empirical therapy / 中国综合临床

Objective To understand the frequency distribution of causes to facilitate the diagnosis and treatment of chronic cough.Methods Patients were recruited according to the inclusion criteria:chronic cough more than 8 weeks;normal X-ray appearance;coughing symptoms as the main or only symptom.Disease history was referred and physical examination was conducted,according to the diagnosis criteria of chronic cough causeoriented processes.If laboratory examination results are missing for a patient,empirical treatment will be combined as a treatment for this patient.Finally,the curative effect and the cause of disease will be analyzed.Results Seventy-nine patients were followed up.Twenty-eight,12,22,10,and 7 patients respectively were suspected of having CVA,EB,UACS,AC and GERC,among whom,23,9,14,9 and 4 were confirmed for their diagnosis,and 84.1％,75.0％,63.6％,90.0％,and 57.1％ of them received effective targeted therapies,accounting for 29.1％,11.4％,24.1％,11.4％,and 6.3％ respectively of all patients.The overall response rate was 74.7％.Conclusion The diagnosis and treatment of chronic cough with combinational cause-oriented diagnostic process and empirical therapy produce high effective rate with low cost.In addition,it could help understand the local frequency distribution of causes of chronic cough.It may be worth wide clinical application.

El proceso diagnóstico y su enseñanza en la medicina / The diagnostic process and its teaching in medicine

El método clínico constituye una categoría fundamental en las Ciencias Clínicas y su utilización como método de enseñanza en las disciplinas y asignaturas en el ciclo clínico de la carrera de Medicina. Contribuye a la sistematización de todas aquellas habilidades que, en forma de sistema, se integran en la ejecución del mismo. El desarrollo de estas habilidades es esencial en el proceso de diagnóstico en Medicina Este artículo tiene como propósito su vinculación a la tarea docente de la Discusión Diagnóstica dentro de la Educación en el Trabajo con recursos didáctico-metodológicos con fines docentes para la enseñanza y aprendizaje de habilidades profesionales del futuro médico.

The clinical method constitutes a fundamental category in the clinical sciences and its utilization as a teaching method in the disciplines and subjects of study in the clinical cycle of Medicine's race. Contribute to the systematization of all those abilities that, in the shape of system. They integrate in the execution of the same one. The development of these abilities is fundamental in the process of diagnosis in medicine the article has as a fundamental purpose its linkage to the teaching task of Diagnostic Discussion within the on-the-job education with didactic resources methodologists with teaching ends for the teaching and learning of professional abilities of the medical future.

A contribuição da análise das noções de espaço, tempo e causalidade nas técnicas projetivas diagnósticas: ludodiagnóstico e desenho da figura humana / Space, time and causality analysis contribution in projective diagnostics technique: ludodiagnostic and a draw-a-person test / La contribución de análisis de las nociones de espacio, tiempo y causalidad en las técnicas proyectivas diagnósticas: ludodiagnóstico y diseño de la figura humana

O pressuposto é que a teoria de Jean Piaget contribui para o diagnóstico clínico de crianças. O objetivo é verificar a relevância dos aspectos cognitivos na análise de testes e técnicas projetivas utilizados no diagnóstico psicológico de crianças. O método consistiu em analisar as noções de espaço, tempo e causalidade, tal como entendidos pela teoria do conhecimento de Piaget em protocolos de ludodiagnóstico e desenho da figura humana de crianças de 2 a 14 anos, atendidas na clínica-escola. Foram analisados 282 protocolos de sessões clínicas ludodiagnósticas, 55 protocolos de testes projetivos do desenho da figura humana e 123 protocolos de ludodiagnósticos de crianças de 2 a 14 anos de escolas particulares. Os resultados demonstraram a relevância da análise desses indicadores cognitivos para a conclusão diagnóstica, ressaltando o valor do ludodiagnóstico como técnica projetiva para tais investigações cognitivas em contraposição ao desenho da figura humana, que não possibilita tais investigações.

The presupposition is that the Piaget's theory contributes in the child diagnostic clinic. The objective is investigates cognitive aspects relevance in projective tests using in the psychologies children diagnostics. The method was analyzed the notions of space, time and causality, as understood by know ledge Piaget's theory of the projective play technique and Draw-a-Person Test between 2 and 14 years old children's protocols, attending in the last six years in psychology clinics. They were analyzed 282 children clinic notes sessions, 55 from projective test of Draw-a-Person Test and 123 notes play technique of children between 2 and 14 years old from private school. The results demonstrated the relevance cognitive as indicators to the child conclusion diagnostic representation process and the relevance play technique as a expressive cognitive diagnostic instrument, opposing to the Draw-a-Person Test that could not give this analyzes.

El presupuesto es que la teoria de Jean Piaget contribuye para lo diagnóstico clínico de niños. El objetivo fué verificar la relevancia de los aspectos cognitivos en el análisis de tests y técnicas proyectivas utilizadas en el diagnóstico psicológico de niños. El método consistió en analizar las nociones de espacio, tiempo y causalidad de la manera como son entendidas por la teoría del conocimiento de Piaget en protocolos de ludodiagnóstico y dibujo de la figura humana de niños entre 2 y 14 años, atendidos en la clínica-escuela de universidad. Fueron analisados 282 protocolos de sessiones clínicas ludodiagnóstico; 55 protocolos de testes proyectivos del dibujo de la figura humana y 123 protocolos de ludodiagnóstico de niños de 2 a 14 años de escuelas particulares. Los resultados demostraron el valor del ludodiagnóstico como técnica proyectiva para esas investigaciones cognitivas en contraposición al dibujo de la figura humana que no posibilitó tales investigaciones.

Comparison of the Outpatient Diagnostic Process Between Novice and Trained Residents / General Medicine

<b>Objective</b> : The outpatient diagnostic processes of novice and trained residents were compared, as to the working diagnosis time and the correct tentative diagnosis rate after history taking to the final diagnosis.<br><b>Methods</b> : Three physicians who had received outpatient training in our department for ≥2 years were defined as “trained residents”, and another three physicians participated in this study from their first day of training at the outpatient clinic were defined as “novice residents”. The study was done at Chiba University Hospital in Japan. The working diagnosis time was defined as the time for the physicians to make a tentative diagnosis for each patient based on history taking, and was calculated from the starting and ending times entered into a computer. By comparing the working diagnoses and the final diagnoses, the correct diagnosis rate was determined for each physician.<br><b>Results</b> : The correct diagnosis rates for trained residents were 87%, 87%, and 85%, respectively. These rates were significantly higher than those of novice residents, which were 73%, 69%, and 55%, respectively (all P<0.001). The working diagnosis times of trained residents were significantly shorter than those of novice residents (all P<0.001). The trained residents still made mostly correct diagnoses after a long time, while the novice residents made more wrong diagnoses as time passed.<br><b>Conclusion</b> : The working diagnosis time was shorter and the correct diagnosis rate was higher in the trained resident group than the novice resident group. Trained residents were able to eventually make a correct diagnosis, even when they failed to make the correct diagnosis initially. On the other hand, the correct tentative diagnosis rate was generally lower for novice residents, and the rate was markedly lower when patients had diseases that could not be diagnosed at an early stage.