Rapid Responses to:

EDITORIALS: Kevin Mackway-Jones The rational clinical examination in emergency care BMJ 2008; 337: a2374 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

How sure can one be?

Sahoo Saddichha   (18 December 2008)

Patient information is central in his surveillance

Alexis Descatha   (18 December 2008)

It's all about risk

James E France   (20 January 2009)

How sure can one be? 18 December 2008
Sahoo Saddichha, Partner, Clinical Research Emergency Management and Research Institute Send response to journal: Re: How sure can one be?	The author [1] has validly raised a point of concern when he says that communication is the key when examining a patient. As a doctor,one is never 100% sure that what he is doing is accurate. In fact, we all perform within reasonable boundaries of doubt and error. However, most patients, as has been rightly suggested, may not see it that way and would, again rightly, want the best care from a health professional. And it is our duty to provide that. Yet, operating from the position that we are in, I would believe that we need to be reasonably honest with our patients. One can well fathom what would happen if we were to reveal every possible side effect of a drug, however rare they may be-we would have a epidemic of imagined and not-so imagined adverse effects on our hands. The only thing that experience teaches a medical professional is how much and what to reveal. References: 1)Mackway-Jones K. The rational clinical examination in emergency care.BMJ 2008;337:a2374 Competing interests: None declared
Patient information is central in his surveillance 18 December 2008
Alexis Descatha, MD PhD UVSQ-AP-HP, EMS 92 (SAMU92)-INSERM U687, Poincare teaching hospital, 92380 Garches, France Send response to journal: Re: Patient information is central in his surveillance	Sir, the editorial of Kevin Mackway-Jones raised a necessary question about patient information. The author asked how we should communicate our decisions based on rational clinical examinations. He insisted on the need to share and communicate our doubt with our patients in a way they understand and accept. The Appelboam et al study (1), discussed by the author, showed that full elbow extension had a likelihood ratio for a negative test of 0.03 (0.01 to 0.08) in adults and a corresponding post-test probability of 1.6% [3.7- 0.5]. Explaining to the patient that they have a very low probability of fracture is crucial, especially because they should return to see a physician if symptoms have not resolved within 10 days, even though the X- ray was performed. Actually, acute elbow injury could correspond to a fracture but many other soft tissue injuries and sometimes X-ray could be difficult to read and miss a fracture. How do we explain to a patient that they should return to see a physician if we have explained to them that they have no fracture or any problem? I think then it‘s essential to explain to our patients why we decided to not perform some complementary investigations in certain cases, especially if we want them to come back to see a physician in case of persistence of symptoms. In conclusion, patient information is central in his surveillance, especially when there are complications. (1) Appelboam A, Reuben AD, Benger JR, Beech F, Dutson J. Haig S, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ 2008;337:a2428 Competing interests: None declared
It's all about risk 20 January 2009
James E France, Consultant Emergency Medicine Worcestershire Royal Hospital, WR5 1DD Send response to journal: Re: It's all about risk	Sir, Professor Mackway-Jones editorial[1] regarding the acceptable sensitivity of diagnostic tests and the level of risk both patient and doctor are prepared to accept raises some interesting issues in emergency medicine. The level of risk an emergency medicine doctor is prepared to accept not only varies with the consequence of not diagnosing a condition but there may also be other factors at work. Patients with the possibility of a subarachnoid haemorrhage and a negative helical CT head scan have a 2% chance of a missed bleed[2] at 12 hours and so undergo a further invasive and inconvenient test (lumbar puncture) which itself may have adverse effects; however patients with a transient ischaemic attack have traditionally been discharged from emergency departments despite the risk of a completed stroke in the next 48 hours being as high as 8%[3]. Recent national guidance suggests an acceptable risk to be 1%[4], much in keeping with the authors of the SWEET trial[5]. Professor Mackway-Jones is right to suggest that patients should be involved in decision making about their own care. However when discussing risk it is clear that even allowing for the differing attitudes of the doctor and patient towards a particular condition or adverse event the way the risk is described is crucial[6]. The verbal description (“uncommon”, “rare”) of a risk frequency is interpreted differently when compared to numerical descriptions using natural frequencies or percentages, both of which are again interpreted differently by doctors and patients. This lack of shared understanding has implications for informed decision making. 1. Mackway-Jones K. the rational clinical examination in emergency care. BMJ 2008; 337: a2374. 2. Scottish Intercollegiate Guideline Network. Diagnosis and management of headache in adults. Nov 2008. 3. Johnston, S et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 283 – 292. 4. National Institute for Health and Clinical Excellence. Diagnosis and in initial management of stroke and transient ischaemic attack (TIA). July 2008. 5. Appelboam A et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ 2008; 337: a2428. 6. France J, Keen C, Bowyer S. Communicating risk to emergency department patients with chest pain. Emerg Med J 2008; 25: 276-278. Competing interests: None declared