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Understanding uncertainty in medicine : concepts and implications in medical education
Kangmoon Kim,Young-Mee Lee 한국의학교육학회 2018 Korean journal of medical education Vol.30 No.3
In an era of high technology and low trust, acknowledging and coping with uncertainty is more crucial than ever. Medical uncertainty has been considered an innate feature of medicine and medical practice. An intolerance to uncertainty increases physicians’ stress and the effects of burnout and may be a potential threat to patient safety. Understanding medical uncertainty and acquiring proper coping strategies has been regarded to be a core clinical competency for medical graduates and trainees. Integrating intuition and logic and creating a culture that acknowledges medical uncertainty could be suggested ways to teach medical uncertainty. In this article, the authors describe the concepts of medical uncertainty, its influences on physicians and on medical students toward medical decision making, the role of tolerance/intolerance to uncertainty, and proposed strategies to improve coping with medical uncertainty.
Ophthalmic Manifestations of Cavernous Sinus Syndrome in a Yorkshire Terrier Dog
Kangmoon Seo 한국임상수의학회 2023 한국임상수의학회지 Vol.40 No.5
A 7-year-old castrated male Yorkshire Terrier presented for a palpable mass of the right neck with ophthalmic signs of conjunctival hyperemia and anisocoria with fixed mydriatic pupil of the right eye. Clinical examination find- ings included the absence of direct and consensual pupillary light reflexes, ex- ternal and internal ophthalmoplegia, and corneal hypoesthesia with incomplete blinking of the right eye. Magnetic resonance imaging and computed tomogra- phy revealed a mass extending from the right cavernous sinus to the orbital fis- sure with neighboring bone lysis. Cytological examination of fine-needle aspira- tion samples of the mass revealed a neuroendocrine tumor. The owner declined further diagnosis and did not wish to care for the dog receiving chemotherapy. This study describes the importance of investigating neuro-ophthalmic findings, which might provide clues for the localization of lesions, including tumors, to aid in diagnosis.
A Case of Choroidal Melanocytoma with Optic Nerve Involvement in a Dog
Kangmoon Seo 한국임상수의학회 2023 한국임상수의학회지 Vol.40 No.4
A 10-year-old spayed female beagle dog presented with a 2-month history of third-eyelid elevation in the left eye (OS). Ophthalmic examination re- vealed slightly diminished corneal and palpebral reflexes along with exophthal- mos in the OS. Schirmer’s tear test and intraocular pressure values were within the normal range for the OS. Slit-lamp biomicroscopy revealed protrusion of the third eyelid and corneal opacity in the OS. Fundoscopy revealed a prominent black mass in the OS covering the optic nerve. Tapetal hyper-reflectivity was also observed around the mass. Ocular ultrasonography showed a 0.74 × 0.67 cm echogenic posterior segment mass around the optic nerve protruding into the retrobulbar space. Computed tomography revealed a contrast-enhanced soft tis- sue lesion in the posteromedial aspect of the left eyeball protruding into the ret- robulbar region, and the optic nerve was suspected to be involved. No evidence of osteolytic changes in the adjacent bone or distant metastasis was observed. Enucleation was performed to prevent potential metastasis or local invasion of the mass and to relieve discomfort due to exposure to keratopathy resulting from lagophthalmos. Histopathological examination revealed a central choroidal melanocytoma extending into the optic nerve. No local recurrence was detected until 16 months postoperatively.
Kim Kangmoon 한국의학교육학회 2022 Korean journal of medical education Vol.34 No.3
Purpose: Despite attempts to teach medical students and trainees about uncertainty in medical practice and how to tolerate it, studies on how to promote tolerance to uncertainty remain scarce. this study aims to investigate factors that could foster residents’ tolerance to uncertainty.Methods: The authors used data sources, including semi-structured individual in-depth interviews with 20 medical residents working in two tertiary university hospitals. Inductive analysis of interview records determined key themes, identified categories, and performed a theoretical-type analysis of the participants’ coping behaviors according to the attributes of uncertainty tolerance.Results: Two characteristics of residents which could lead to constructive coping with uncertainty were discovered: (1) communicative/collaborative behavior with their colleagues, superiors, and patients and (2) self-reflective/self-directed attitude in their medical practice. Both were used to classify four types of uncertainty coping behaviors: adaptive, self-contained, submissive, and isolated.Conclusion: Fostering communicative/collaborative behaviors and self-reflective/self-directed attitude throughout the training period may result in residents being more tolerant of uncertainties in medical practice.
Su An Kim,Jaeho Shim,Seonmi Kang,Kangmoon Seo 대한수의학회 2023 Journal of Veterinary Science Vol.24 No.4
Background: There has not been a thoroughly reported study of the comparison between spectral domain-optical coherence tomography (SD-OCT) with both ultrasound biomicroscopy (UBM) and gonioscopy on the evaluation of the iridocorneal angle (ICA) in dogs. Objectives: To investigate the diagnostic value of SD-OCT for the early detection of narrowing ICA by comparing and assessing inter-device agreement in anterior chamber angle (ACA) measurements obtained by SD-OCT and UBM, and ICA evaluations by gonioscopy. Methods: A total of 28 eyes from 28 client-owned dogs with normal intraocular pressure were included for examination. The ACA and angle opening distance (AOD) were measured from the SD-OCT and UBM images, and gonioscopy images were analyzed using the ICA grade and ZibWest angle index. Results: The mean ACA and AOD for SD-OCT were 28.31° ± 5.37° and 658.42 ± 219.90 μm, and for UBM, 28.34° ± 5.82° and 859.29 ± 221.80 μm, respectively. The mean difference in ACA between the average values of SD-OCT and UBM measurements was 0.03° with a 95% limit of agreement (LoA) span of 16.2°, indicating positive agreement; that in AOD was 200.85 μm with a 95% LoA span of 1,110.95 μm, indicating poor agreement. The Pearson correlation coefficient of the ACA of SD-OCT and ZibWest indices of gonioscopy was 0.624, indicating strong agreement; that of UBM and gonioscopy was 0.43, indicating moderate agreement. Conclusions: SD-OCT is well tolerated by canine patients due to its non-contact method and might be an alternative option for early screening of ICA narrowing in clinical settings.
Hyelin Kim,Youngseok Jeong,Eunji Lee,Kangmoon Seo,Seonmi Kang 대한수의학회 2023 Journal of Veterinary Science Vol.24 No.5
Two dogs presented with bilateral pattern-forming corneal opacity. Treatment with topical immunosuppressants was initiated after a complete ophthalmic examination. The response to treatment was assessed by analyzing serial images using slit-lamp biomicroscopy and spectral domain optical coherence tomography (SD-OCT). Both dogs responded to topical immunosuppressants; however, the lesions recurred once the treatment was abated or withdrawn. The most effective immunosuppressant in both dogs was 0.03% tacrolimus ointment. Early and continuous treatment with topical immunosuppressants may be necessary to improve corneal clarity and prevent scarring. SD-OCT could provide useful structural information regarding presumed immune-mediated keratitis and aid in monitoring treatment response.
Eunji Lee,Seonmi Kang,Dajeong Jeong,Kangmoon Seo 대한수의학회 2023 Journal of Veterinary Science Vol.24 No.6
Background: Long-term comparisons of phacoemulsification with topical medication are limited in canine diabetic cataracts. Objectives: To compare outcomes of eyes submitted to phacoemulsification with those of topical medication for canine diabetic cataracts and identify risk factors for complications. Methods: Through medical records review, 150 eyes (76 dogs) with diabetic cataracts were included; 58 eyes (31 dogs) underwent phacoemulsification (phaco-group) and 92 eyes (48 dogs) received ophthalmic solution alone (medication-group). The medicationgroup was divided into owner-led and vet-led groups depending on who elected not to perform surgery. Comparisons involved time-to-complications, vision, and the number and type of ophthalmic solutions administered. The association between complications and pretreatment clinical findings was investigated. Results: No difference was found in complication risk between the phaco and owner-led medication groups. Conversely, the vet-led medication-group had a higher complication risk than the other groups. At the last follow-up, 94.8% of the phaco-group had vision, whereas 7.6% of the medication-group restored some visual axis. Poor glycemic control in the medication-group and younger age in the phaco-group increased complication risk. At 1-year post-treatment, the average number of ophthalmic solutions administered was 1.7 and 2.6 in the phaco and medication groups, respectively. The medication-group used anti-inflammatories the most throughout the follow-up, whereas the phaco-group used anti-inflammatories the most until 1-year post-treatment and lacrimostimulants at 1.5-year post-treatment. Conclusions: For canine diabetic cataracts, phacoemulsification is recommended because it is superior to topical management alone in terms of maintaining vision and reducing the number of ophthalmic solutions required in the long term.