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Smile if you’re having a PE. EMJ

16 Aug, 16 | by scarley

This week we have a new study from the fabulous Jeffrey Kline looking at whether the probability of a patient’s smile affects the likelihood of a positive diagnosis for PE.

Jeff has an amazing track record in PE research. He’s also a competitive bodybuilder which has nothing to do with PE, research or this article, it’s just that I am really impressed.

At first glance this may seem a bit weird and perhaps you were going to look at whether SMILE was an acronym for some new scoring system, but no. We are really talking about smiles from the patient. I find this stuff fascinating as I’m a great believer that we pick up subtle clues from patients that influence our perception of illness and thus affect our decisions. No doubt you will all have experienced the patient who ‘looks sick’ but the numbers are OK. That sixth sense, gestalt, judgement, whatever you wish to call it is important. It changes what we do and how we think but there is a paucity of research out there.

You may already have read Jeff’s work on facial expression in cardiovascular disease and if not you probably should which suggests that patients do have different facial reactions depending on their underlying diagnosis. Maybe there is something in this.

In this EMJ paper the question of the smile is examined. The abstract is below (but read the full paper please). Does it make a difference. Well yes and no would be a fair conclusion. It changes the way that we think but perhaps not what we do.

Screenshot 2016-08-13 13.52.08So, an interesting insight into some of the art of emergency medicine? Perhaps. We’d love to hear what you think.







The Science Behind Telling “Sick” From “Not Sick”

31 Jul, 14 | by rradecki

Jeff Kline contributed a very interesting article to the Emergency Medicine Journal last week – offering up a bit of a potential science behind the “gestalt” in medicine. We’ve seen multiple examples where clinician gestalt performance is very similar to carefully-derived, evidence-based, risk-stratification criteria. Specifically, the diagnoses of “acute coronary syndrome” and “pulmonary embolism” have been evaluated in the past – and only the newest attribute-matching tools have offered any promise regarding improving upon simple clinician judgement.

This newest study from Kline, et al, evaluated 50 patients in the Emergency Department and their facial reactions to visual cues. It turned out, the 18 patients from this cohort ultimately diagnosed with significant cardiovascular syndromes displayed significantly decreased expressive variability when prompted with multiple stimuli. The reasonable conclusion, therefore, is patients with serious diagnoses may exhibit measurable, reproducible behavior changes. A small study, to be sure, but hence the idea – there is something encoded in our emotional intelligence helping us evaluate “sick” from “not sick” in the Emergency Department.

Supposing this observation holds up to further scrutiny, the results do not surprise me at all. Part of clinical training in Emergency Medicine involves simple voluminous exposure to as many patients as feasible. The behaviors of each different patient, their clinical features, and their outcomes become encoded in this entity, the clinician “gestalt”. And, what this study reflects is something we all recognize – a patient is not simply a collection of risk factors, or a Revised Geneva Score – the physicality associated with how a patient exists in the examination room provides additional information. The intuition of the experienced clinician, then, may be based as much in reading patients’ faces as it is synthesizing clinical knowledge.

This has interesting implications for other developments in medicine, as well. The time pressures in Emergency Medicine, or in other outpatient settings, that simply cut down on time spent with each patient, may detract from the quality of the evaluation. Telemedicine, another technological advance aimed at diluting and expanding coverage, may suffer as a result of diminished communication of these critical nonverbal cues.

Regardless, this study is quite unique in the spectrum of Emergency Medicine research, and hopefully inspires a follow-up generation of research.  Or, alternatively, what would you say forms the basis of our “gestalt”?

Link: “Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting






Ryan Radecki

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