Objective:To compare the results of urine cultures and reagent strip testing in 2 groups of elderly emergency department (ED) patients: an asymptomatic group unlikely to have urinary tract infection (UTI), and a group who had vague symptoms and were considered at risk for UTI. Methods: We performed a prospective observational convenience study with 2 groups of 100 patients aged 65 or older. The asymptomatic group consisted of afebrile patients presenting to the ED with non-infectious complaints, while the symptomatic group included patients presenting with acute confusion, weakness or fever but no apparent urinary symptoms. We defined a positive urine culture as a single organism count greater than 100 000 CFU/mL in mid-stream specimens, or greater than 1000 CFU/mL in catheter specimens. We considered reagent strips positive if they demonstrated any reaction to the leukocyte-esterase assay, the nitrite assay or both. Results: Of the 33 positive cultures, 10 had negative reagent strips. Thirteen of the 14 positive nitrite tests were culture positive for a specificity of 92.8% and a sensitivity of 36.1%. Positive cultures did not infer a diagnosis of UTI. Of the 67 positive reagent strips, 41 (61.2%) were associated with negative cultures. Likelihood ratios (LRs) in both groups affirmed the inability of the reagent strips to help significantly in decision making, with positive and negative LR in the indeterminate range (control group: 2.8 and 0.31, symptomatic group: 2.7 and 0.46, respectively). Conclusion: In the elderly, reagent testing is an unreliable method of identifying patients with positive blood cultures. Moreover, positive urine culture rates are only slightly higher in patients with vague symptoms attributable to UTI than they are in (asymptomatic) patients treated for non-urologic problems, which suggests that many positive cultures in elderly patients with nonfocal systemic symptoms are false-positive tests reflecting asymptomatic bacteriuria and not UTIs. Blood cultures, regarded by many as the criterion standard for UTI, do not have sufficient specificity to confirm the diagnosis of UTI in elderly patients with non-specific symptoms.

No abstract

No abstract

Objectives: Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training. Methods: Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences.Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy. Results:The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training.Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy. Conclusions:The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

Like many other disciplines, medicine often resorts to metaphor in order to explain complicated concepts that are imperfectly understood. But what happens when medicine's metaphors close off thinking, restricting interpretations and opinions to those of the negative kind? This paper considers the deleterious effects of destructive metaphors that cluster around pain. First, the metaphoric basis of all knowledge is introduced. Next, a particular subset of medical metaphors in the domain of neurology (doors/keys/wires) are shown to encourage mechanistic thinking. Because schematics are often used in medical textbooks to simplify the complex, this paper traces the visual metaphors implied in such schematics. Mechanistic-metaphorical thinking results in the accumulation of vast amounts of data through experimentation, but this paper asks what the real value of the information is since patients can generally only expect modest benefits – or none at all – for relief from chronic pain conditions. Elucidation of mechanism through careful experimentation creates an illusion of vast medical knowledge that, to a significant degree, is metaphor-based. This paper argues that for pain outcomes to change, our metaphors must change first.

No abstract

This article has been peer reviewed.

In Part I, I described evidence-based medicine (EBM) as a methodology that potentiates the biomedical epistemology. I used my own story (disabled physician educated at the height of institutional adoption of EBM pedagogy) as substrate upon which EBM worked, starting the timeline at 1975. Part II proceeds on much the same terms, but covers a chronology in which the critique concerning EBM intensifies, yet an entrenched EBM persists. Through the lyric essay technique of juxtaposition and by employing lived experience in the narration, it is my hope that EBM is encountered in the way most of us still encounter it: a data-rich lurch into the sideways.