1. Class 13 2011/2012 Introdução à Medicina II What are the concepts of problem and diagnosis according to physicians? Final Presentation: 25.05.2012

2. Index Introduction Aims Methods Results Discussion Aknowledgements 2 Class 13 2011/2012 Introdução à Medicina II

3. PROBLEM Everything that requires diagnosis or acompaniment or interferes with the patient’s quality of life in a noticeable way. [1] DIAGNOSIS References: [1] Kaplan DM, “Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees”. 2010 Oct; 85(10): 1578-82 [2] Definition of the term “diagnosis” [MeSH] according to Pubmed The determination of the nature of a disease or condition, or the distinguishing of one disease or condition from another. [2] Introduction Aims Methods Results 3 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

4. Lawrence Weed (1969): -individuality, -continuity, -present - past dynamic, -information sharing. List of Problems: Active and Passive [4,5] References: [3] Weed, L. “Medical Records that Guide and Teach.” New England Journal of Medicine 278, no. 11 (1968): 593–600 [4] Queiroz, MJ; “Os diferentes passos da consulta e os registos clínicos”; Faculdade de Ciências Médicas da Universidade Nova de Lisboa (2010). The Origin of the Concept: PROBLEM SOAP : Subjective, Objective, Assessment, Planning Introduction Aims Methods Results 4 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

5. CLINICAL EXAMINATIONS ORIGINS Primitive: “medicine-men” searched for causes of diseases – spiritual and divine signs. Not methodic, illogical and influenced by beliefs and religion. But… had the same purpose of medical diagnosis: search for causes of diseases in order to fight them. [5] BASIS OF MEDICAL DIAGNOSIS References: [5] Kenneth, D Kule, “The Evolution of Clinical Methods in Medicine” Ed. Citman Medical The Origin of the Concept: DIAGNOSIS Introduction Aims Methods Results 5 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

6. NURSING DIAGNOSIS Nursing Diagnosis: steps [6] 1.Decade 20: Difference Medical Problem – Nursing Problem 2.Decade 50: Concept of diagnosis in applied in Nursing Activity 3.1973: American Conference: Classification of Nursing Diagnosis 4.1982: Fundation of NANDA (North American Nursing Diagnosis Association) References: [6] Isabel Cristina Fonseca da Cruz, “A Evolução Hitórica do Conceito Diagnóstico de Enfermagem”, Apresentado no I Simpósio Nacional sobre Diagnósticos de Enfermagem. São Paulo, Nov/1991 e publicado nos Anais. Introduction Aims Methods Results 6 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

7. MEDICAL DIAGNOSIS 1. Primitive thinking 2. Developing of different techniques in Ancient Egypth, Greece, Rome… 3. Oslerian Ideal: Relation Natural Human Mechanisms and its disorders (1900) 4. Separation Medical Problem /Nursing Problem 5. Medical Diagnosis / Nursing Diagnosis Introduction Aims Methods Results 7 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

8. MISMATCH IN MEDICAL PRACTICE delay Diagnosis, treatment harm correct flow of the clinical procedures Concept differences Introduction Aims Methods Results 8 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

9. MISMATCH IN MANAGEMENT OF RESOURCES Lead to Bad distribution of human and monetary resources Deficiencies in those procedures development cause False records of clinical procedures Statistics Reports with bias and false information Concept Differences Mismatch in Clinical Records Lack of information in clinical records Introduction Aims Methods Results 9 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

10. MISMATCH IN CLINICAL RESEARCH Lead to Ambiguous and biased conclusions Waste of resources cause Misrepresentation of the causes and outcomes of the problem in study Concept Differences Difficulty in defining as diagnosis or problem the outcomes and variables in the investigation Introduction Aims Methods Results 10 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

11. So… An appropriate pacient diagnosis and treatment Management of resources Correct clinical research The clarification of these two concepts is really important to: Introduction Aims Methods Results 11 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

12. Specific Aims: General Aim: To evaluate the differences between diagnosis and problem concepts among physicians To make an association between those differences and: Responsable for Encoding Workplace environment (hospital/primary care); Graduation Institution ( FMUP/ICBAS) Graduation Period Introduction Aims Methods Results 12 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

13. Expert Survey: 4 teachers and specialists (related to the registry of medical information) Field Survey: Randomized Sampling of Oporto physicians from 2 hospitals: HSJ (n=14) and HGSA (n = 28) and 1 primary care: CSSJ (n=7) Encoders that didn’t belong to the previous groups (n= 4) Responses Total: 53 Survey’s delivered: 150 Response Rate ≈ 35 % Response Rate from: HSJ, (75 questionnaires delivered), ≈ 19%, HGSA, (60 questionnaires delivered) ≈ 47% CSSJ, (15 questionnaires delivered), ≈ 47%. STUDY PARTICIPANTS: Introduction Aims Methods Results 13 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

14. STUDY DESIGN: Observational; Cross sectional Analytical; Introduction Aims Methods Results 14 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

15. Expert Survey: (Face-to-face Interviews) Field Survey: Self Admnistered Questionnaries DATA COLLECTION METHODS: Introduction Aims Methods Results 15 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

16. Biographical Data The Importance of Concept’s Distinction in Medical Practice The Distinction between Problem and Diagnosis The Practice Application of the two concepts The Most Significant Variables Opinions about the Pilot Survey Interviews’ organization Introduction Aims Methods Results 16 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

17. Group I Personal definition of the concepts problem and diagnosis. Group II List of items for diagnosis and problems. Group III Matching of Concept’s definitions. Personal Information Questionnaries’ organization Introduction Aims Methods Results 17 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

18. VARIABLES DESCRIPTION: Responsable for Encoding Workplace environment (hospital/primary care); Graduation Institution ( FMUP/ICBAS) Graduation Period (before 2000/ 2000 and after) Concept’s definitions List of items for diagnosis and problems Matching of Concept’s definitions. Introduction Aims Methods Results 18 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

19. STATISTICAL ANALYSIS Field Survey’s Data  Statistical Package for Social Sciences (SPSS): - Analysis of the frequency of each answer; - Comparison of the answers according to: - Responsable for Encoding - Workplace environment (hospital/primary care); - Graduation Institution ( FMUP/ICBAS) - Graduation Period -Qui-Square Test (Statistical analysis was performed, but no significant result was obtained, due to the lack of data.) Introduction Aims Methods Results 19 Class 13 2011/2012 Introdução à Medicina II Discussion Aknowledge ments

20. Dr. Fernando Lopes Responsable for clinical encoding in HSJ Dr. Altamiro Pereira Responsable for “Introdução à Medicina” in FMUP Dr. Paulo Bettencourt Responsable for “Semiótica Clínica” in FMUP Dr. Amaral Bernardo Responsable for “Semiologia Médica e Cirúrgica” in ICBAS Expert’s Survey: INTERVIEWS Respondents 20 Class 13 2011/2012 Introdução à Medicina II Introduction Aims Methods Results Discussion Aknowledge ments

21. Different Concepts of Problem and Diagnosis Lack of consensus Different Opinions about the Importance in Clinical Practice Clinical Research Encoding Significant Variables: Profession Task and Experience Suggestions for the Questionnary Interviews’ Results Introduction Aims Methods Results 21 Class 13 2011/2012 Introdução à Medicina II Expert’s Survey: INTERVIEWS Discussion Aknowledge ments

22. General Results : Group I, Diagnosis Introduction Aims Methods Results 22 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Discussion Aknowledge ments

23. Introduction Aims Methods Results 23 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES General Results : Group I, Problem Discussion Aknowledge ments

24. Introduction Aims Methods Results 24 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES General Results : Group II Discussion Aknowledge ments

25. Introduction Aims Methods Results 25 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES General Results : Group III Discussion Aknowledge ments

26. Introduction Aims Methods Results 26 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Encoders/Non Encoders, Group I, Problem Discussion Aknowledge ments

27. Introduction Aims Methods Results 27 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Encoders/Non Encoders, Group I, Diagnosis Discussion Aknowledge ments

28. Introduction Aims Methods Results 28 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Encoders/Non-Encoders, Group II Discussion Aknowledge ments

29. Introduction Aims Methods Results 29 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Encoders/Non-Encoders, Group III Discussion Aknowledge ments

30. Introduction Aims Methods Results 30 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Workplace Environment, Group I, Problem Discussion Aknowledge ments

31. Introduction Aims Methods Results 31 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Workplace Environment, Group I, Diagnosis Discussion Aknowledge ments

32. Introduction Aims Methods Results 32 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Workplace Environment, Group II Discussion Aknowledge ments

33. Introduction Aims Methods Results 33 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Workplace Environment, Group III Discussion Aknowledge ments

34. Introduction Aims Methods Results 34 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Institution, Group I, Problem Discussion Aknowledge ments

35. Introduction Aims Methods Results 35 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Institution, Group I, Diagnosis Discussion Aknowledge ments

36. Introduction Aims Methods Results 36 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Institution, Group II Discussion Aknowledge ments

37. Introduction Aims Methods Results 37 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Institution, Group III Discussion Aknowledge ments

38. Introduction Aims Methods Results 38 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Period, Group I, Problem Discussion Aknowledge ments

39. Introduction Aims Methods Results 39 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Period, Group I, Diagnosis Discussion Aknowledge ments

40. Introduction Aims Methods Results 40 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Period, Group II Discussion Aknowledge ments

41. Introduction Aims Methods Results Discussion 41 Class 13 2011/2012 Introdução à Medicina II Field Survey: QUESTIONNARIES Comparison: Graduation Period, Group III Aknowledge ments

42. Main Findings: Diagnosis: Myocardial Infarction, CVA (stroke), Asthma, Migraines, Pulmonary infection, Acute bronchitis, Head Injury, Infected Wound Problems: Headaches, Chest pain, Fainting, Blurred vision, Itching and Skin Irritation, Blisters and Rashes, Blood in sputum, Cough, Vomiting, Prolonged loss of consciousness, Fever, Shortness of breath, Palpitations, Dandruff, Alcohol abuse, Indigestion Introduction Aims Methods Results Discussion Aknowledge ments 42 Discussion

43. Different definitions for the concepts: problem and diagnosis Concept differences mainly between: Encoders/Non-Encoders (minor relevance) Graduation Period ( before 2000/ 2000 and after) (Statistical analysis was performed, but no significant result was obtained, due to the lack of data.) No differences observed between: FMUP/ICBAS (Graduation Institution) Hospital/Primary Care Discussion Introduction Aims Methods Results Discussion Aknowledge ments 43

44. Concept differences between: Encoders/Non-Encoders Management of Resources Clinical Research Generations (Graduation Period) Clinical Practice / Data Sharing affect Introduction Aims Methods Results Discussion Aknowledge ments 44 Discussion

45. LIMITATIONS Lack of responses Lack of simillar work Introduction Aims Methods Results Discussion Aknowledge ments 45 Discussion

46. Dr. Ricardo Correia Dr. Gustavo Bacelar Dr. Altamiro Pereira Dr. Fernando Lopes Dr. Paulo Bettencourt Dr. Amaral Bernardo Acknowledgements Introduction Aims Methods Results Discussion Aknowledge ments 46