Gastroenterology 2015;148:1079–1081
CORRESPONDENCE Readers may submit letters to the editor concerning articles that appeared in Gastroenterology within one month of publication. Detailed guidelines regarding the content are included in the Instructions to Authors.
The Medical History: Form and Function Dear Editor: One does not have to agree completely with Skeff’s analysis and advice1 about writing the patient history to be impressed by it; the appearance of work on this subject matter in a premier specialty journal like Gastroenterology is an achievement in itself. For all the discussion about medical records in generalist journals, and lately in popular media, higher-level academic publications have mostly stayed above this fray, perhaps viewing matters of mere recordkeeping as unworthy of their attention. That is not to say that Skeff has much to say about electronic records; in fact there is little in his document that would have been seen as unusual in the 1970s. I was certainly brought up during that decade to focus clearly on the time order of the patient’s history, but there has since been a general deterioration of timeline focus in medical documents, paper or digital. This likely reflects time pressures and the increased complexity of cases in training environments, where inpatients so frequently have extensive prior medical contacts and technological interventions, both diagnostic and therapeutic, as his examples demonstrate. Skeff offers helpful advice about documenting these events, although the exact mechanics of the process remain somewhat obscure. The examples offered read like handwritten notes and a good typist can execute them reasonably well with liberal use of formatting keys. However, it is unclear how well a nontypist can work to his model, or how it would work now with prevalent voice dictation technology. Nevertheless this is a good start—a robust ongoing discussion would focus on how these historical snippets, still text-based regardless of their brevity, can or should fit together with structured data elements in the modern electronic medical record to produce better diagnostic accuracy. Things certainly seem disorganized in that arena now; without mentioning product names, my personal observation is that most of my specialty colleagues habitually ignore problem lists and structured historical material in the EMR in favor of their own narratives, even when that material, automatically pasted into their templated notes, conflicts with their own text narrative. There seems to be a certain habitual stubbornness at work. Korman has documented the chronic difficulties in convincing gastroenterologists to populate useful structured data fields in endoscopic reports.2 But above all of this is the greater question of whether the traditional method of diagnosis, based on inductive reasoning and heuristics, can ever overcome its inherent tendency toward diagnostic error. Weed has certainly reached the conclusion that it cannot.3 His recent work advocates the replacement of traditional history taking
with an extremely granular data gathering exercise that eschews diagnostic theorizing altogether, with construction of the differential diagnosis left up to knowledge couplers built into the system itself. Suffice it to say that so far application of that approach has not succeeded on a large scale; there is hope that natural language processing and supercomputer technology may lead us in that direction in the near future. Whatever the future of the medical record, academic medicine needs to take a stronger role in shaping it. I congratulate the author and editors for bringing this issue forward. ROBERT D. LAFSKY Loudoun Gastroenterology Lansdowne, Virginia
References 1. 2. 3.
Skeff K. Gastroenterology 2014;147:1208–1211. Korman LY. Clin Gastroenterol Hepatol 2012;10: 956–959. Weed L, et al. Diagnosis 2014;1:13–17.
Conflicts of interest The author discloses no conflicts.
http://dx.doi.org/10.1053/j.gastro.2015.01.049
Intestinal Permeability in Patients With DiarrheaPredominant Irritable Bowel Syndrome: Is There a Place for Glutamine Supplementation? We read with great interest the recent paper published by Zhou et al reporting that upregulation of miR29a in the colonic mucosa of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) is responsible for claudin-1 and nuclear factor-kB-repressing factor reduction leading to increased intestinal permeability.1 These data have been confirmed in miR29-/- mice in both models: water avoidance stress and post-inflammatory colitis. In this paper1, Zhou et al also confirm previous studies showing an increased colonic2 and small intestinal3 permeability in IBS-D patients, with a reduced expression of tight junction proteins, particularly occludin and claudin-1.4 This study also highlights novel putative mechanisms underlying intestinal permeability alteration. In a previous article, these authors have shown that miR29a targets glutamine synthetase mRNA leading to a decreased expression of glutamine synthetase in the small intestinal and colonic mucosa of IBS-D patients.2 Zhou et al
CORRESPONDENCE Readers may submit letters to the editor concerning articles that appeared in Gastroenterology within one month of publication. Detailed guidelines regarding the content are included in the Instructions to Authors.
The Medical History: Form and Function Dear Editor: One does not have to agree completely with Skeff’s analysis and advice1 about writing the patient history to be impressed by it; the appearance of work on this subject matter in a premier specialty journal like Gastroenterology is an achievement in itself. For all the discussion about medical records in generalist journals, and lately in popular media, higher-level academic publications have mostly stayed above this fray, perhaps viewing matters of mere recordkeeping as unworthy of their attention. That is not to say that Skeff has much to say about electronic records; in fact there is little in his document that would have been seen as unusual in the 1970s. I was certainly brought up during that decade to focus clearly on the time order of the patient’s history, but there has since been a general deterioration of timeline focus in medical documents, paper or digital. This likely reflects time pressures and the increased complexity of cases in training environments, where inpatients so frequently have extensive prior medical contacts and technological interventions, both diagnostic and therapeutic, as his examples demonstrate. Skeff offers helpful advice about documenting these events, although the exact mechanics of the process remain somewhat obscure. The examples offered read like handwritten notes and a good typist can execute them reasonably well with liberal use of formatting keys. However, it is unclear how well a nontypist can work to his model, or how it would work now with prevalent voice dictation technology. Nevertheless this is a good start—a robust ongoing discussion would focus on how these historical snippets, still text-based regardless of their brevity, can or should fit together with structured data elements in the modern electronic medical record to produce better diagnostic accuracy. Things certainly seem disorganized in that arena now; without mentioning product names, my personal observation is that most of my specialty colleagues habitually ignore problem lists and structured historical material in the EMR in favor of their own narratives, even when that material, automatically pasted into their templated notes, conflicts with their own text narrative. There seems to be a certain habitual stubbornness at work. Korman has documented the chronic difficulties in convincing gastroenterologists to populate useful structured data fields in endoscopic reports.2 But above all of this is the greater question of whether the traditional method of diagnosis, based on inductive reasoning and heuristics, can ever overcome its inherent tendency toward diagnostic error. Weed has certainly reached the conclusion that it cannot.3 His recent work advocates the replacement of traditional history taking
with an extremely granular data gathering exercise that eschews diagnostic theorizing altogether, with construction of the differential diagnosis left up to knowledge couplers built into the system itself. Suffice it to say that so far application of that approach has not succeeded on a large scale; there is hope that natural language processing and supercomputer technology may lead us in that direction in the near future. Whatever the future of the medical record, academic medicine needs to take a stronger role in shaping it. I congratulate the author and editors for bringing this issue forward. ROBERT D. LAFSKY Loudoun Gastroenterology Lansdowne, Virginia
References 1. 2. 3.
Skeff K. Gastroenterology 2014;147:1208–1211. Korman LY. Clin Gastroenterol Hepatol 2012;10: 956–959. Weed L, et al. Diagnosis 2014;1:13–17.
Conflicts of interest The author discloses no conflicts.
http://dx.doi.org/10.1053/j.gastro.2015.01.049
Intestinal Permeability in Patients With DiarrheaPredominant Irritable Bowel Syndrome: Is There a Place for Glutamine Supplementation? We read with great interest the recent paper published by Zhou et al reporting that upregulation of miR29a in the colonic mucosa of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) is responsible for claudin-1 and nuclear factor-kB-repressing factor reduction leading to increased intestinal permeability.1 These data have been confirmed in miR29-/- mice in both models: water avoidance stress and post-inflammatory colitis. In this paper1, Zhou et al also confirm previous studies showing an increased colonic2 and small intestinal3 permeability in IBS-D patients, with a reduced expression of tight junction proteins, particularly occludin and claudin-1.4 This study also highlights novel putative mechanisms underlying intestinal permeability alteration. In a previous article, these authors have shown that miR29a targets glutamine synthetase mRNA leading to a decreased expression of glutamine synthetase in the small intestinal and colonic mucosa of IBS-D patients.2 Zhou et al
