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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Thinking in context
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Elizabeth A. Bayliss, Denver, CO, USA Clinician Researcher, Kaiser Permanente and UCHSC
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Kataoka and Matsuno’s article on Age-Related Pulmonary Crackles reassures us that it is possible for a patient to have rales on lung exam that do not indicate heart failure or pulmonary disease (especially for older patients).(1) Although the manuscript does not address the question many primary care clinicians will have (what are the chances that the patient in front of me with rales on exam does have cardiac or pulmonary disease?) it reminds us that generalist practice is all about context. Experienced clinicians modify their working diagnosis by the deductive use of evidence as they incorporate different pieces of their history and physical exam—adjusting the ‘post test probability’ of a specific diagnosis with each additional piece of information.(2) However, other factors go into making accurate clinical assessments as well. Continuity helps (a lot) as does the mindful use of ‘clinical intuition’. Greenhalgh describes ‘intuition’ as a scientific and creative process leading to hypothesis generation, and suggests that it be used along with deductive principles of evidence-based medicine in reaching diagnoses.(3) This article adds to the evidence base for evaluating cardiopulmonary disease by providing additional rationale to avoid leaping to premature diagnostic conclusions based on the presence of rales on physical exam. In doing so it argues indirectly for using additional evidence, context, and ‘intuition’ as needed to accurately frame a diagnostic presentation. It is also a reminder that algorithm-driven care based on a strict assessment of signs and symptoms may be less relevant for many patients as they age. (1) Kataoka H, Matsuno O. Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients. Ann Fam Med 2008;6(3):239-45. (2) Gill CJ, Sabin L, Schmid CH. Why clinicians are natural bayesians. BMJ 2005 May 7;330(7499):1080-3. (3) Greenhalgh T. Intuition and evidence--uneasy bedfellows? Br J Gen Pract 2002 May;52(478):395-400. Competing interests: None declared |
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