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The Sherlock Holmes method in clinical practice
El método de Sherlock Holmes en la práctica clínica
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Abbreviations: ASA, acetylsalicylic acid; AF, atrial fibrillation; CV, cardiovascular; OAC, oral anticoagulants. * For example: With recurrent thrombotic events, stent-carrying patients, research studies. ** Considering factors such as advanced age, poorly controlled hypertension, previous bleeding and concomitant medication.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Castilla-Guerra, M.S. Navas-Alcántara, M.C. Fernández-Moreno" "autores" => array:3 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Castilla-Guerra" ] 1 => array:2 [ "nombre" => "M.S." "apellidos" => "Navas-Alcántara" ] 2 => array:2 [ "nombre" => "M.C." 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Sopeña" "autores" => array:1 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Sopeña" "email" => array:1 [ 0 => "bernardosopena@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Trombosis y Vasculitis, Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Pontevedra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El método de Sherlock Holmes en la práctica clínica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1887, Sir Arthur Conan Doyle (Edinburgh, 1859–1930), while practicing general medicine in Portsmouth, published the novel “A Study in Scarlet”, with which he began his career with Sherlock Holmes. This work reveals the foundations of the science of deduction, an intellectual tool with which he solves the 60 cases that make up the complete works of the detective. In each episode, Holmes attempts to show his methods to Dr. Watson and to those who take an intelligent interest in them (The Reigate Squires, p. 278).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The Holmes method</span><p id="par0010" class="elsevierStylePara elsevierViewall">This method is based on the preparation of a hypothesis based on information collected through detailed observation, careful listening and thorough examination. The most characteristic element of the Holmes method is the ability to detect and give relevance to small details that are usually “<span class="elsevierStyleItalic">the basis of the deduction</span>” (The Crooked Man, p. 930). In fact, Holmes defines it thusly: “<span class="elsevierStyleItalic">You know my method. It is founded upon the observation of trifles</span>” (The Boscombe Valley Mystery, p. 841).</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Holmes method highlights the importance of deductive reasoning, which analyzes the data received with the goal of separating the essential from the accessory: “<span class="elsevierStyleItalic">The principal difficulty in your case – remarked Holmes – lay in the fact of there being too much evidence. What was vital was overlaid and hidden by what was irrelevant. Of all the facts which were presented to us, we had to pick just those which we deemed to be essential, and then piece them together in their order, so as to reconstruct this very remarkable chain of events</span>” (The Naval Treaty, p. 890).</p><p id="par0020" class="elsevierStylePara elsevierViewall">This screening of information has the purpose of identifying, as soon as possible, the key clue that allows us to solve the puzzle, with the greatest efficiency of time and resources: “<span class="elsevierStyleItalic">It is remarkable only for the fact that amid a perfect jungle of possibilities we, with our worthy collaborator, the inspector, have kept our close hold on the essentials and so been guided along the crooked and winding path</span>” (The Adventure of Wisteria Lodge, p. 969).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Let us now analyze its main components.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Detailed observation</span><p id="par0030" class="elsevierStylePara elsevierViewall">From the moment Holmes receives a request for assistance, either in writing establishing the problem or on arrival of the person who seeks his services, he sharpens his intense powers of observation: “<span class="elsevierStyleItalic">Mr. James M. Dodd seemed somewhat at a loss how to begin the interview. I did not attempt to help him, for his silence gave me more time for observation</span>” (The Adventure of the blanched soldier, pp. 1461–1462). What is characteristic of Holmes’ method of observing is his effort to extract all information contained in what he analyzes without omitting any detail.<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">‘I can see nothing,’ said I, handing it [the hat] back to my friend.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">‘On the contrary,’ Watson, you can see everything. You fail, however, to reason from what you see.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">‘Then, pray tell me what it is that you can infer from this hat?’</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">He picked it up and gazed at it in the peculiar introspective fashion which was characteristic of him.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">…That the man was highly intellectual is of course obvious upon the face of it, and also that he was fairly well-to-do within the last three years, although he has now fallen upon evil days. He had foresight, but has less now than formerly, pointing to a moral retrogression, which, when taken with the decline of his fortunes, seems to indicate some evil influence, probably drink, at work upon him. This may account also for the obvious fact that his wife has ceased to love him He is a man who leads a sedentary life, goes out little, is out of training entirely, is middle-aged, has grizzled hair which he has had cut within the last few days, and which he anoints with lime-cream” (The Adventure of the Blue Carbuncle, p. 391).</p></span></p><p id="par0035" class="elsevierStylePara elsevierViewall">For Holmes, observation and deduction are inseparable. Therefore, while observation looks for the most useful aspects to verify the hypothesis, knowing what you want to find illuminates the reality and highlights the details:<span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">“You appeared to read a good deal upon her which was quite invisible to me.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Not invisible but unnoticed, Watson. You did not know where to look, and so you missed all that was important” (A Case of Identity, p. 347).</p></span></p><p id="par0040" class="elsevierStylePara elsevierViewall">This ability to detect trifles and letting nothing escape, however irrelevant it seems, requires an active mind and a high level of concentration. It is not an innate quality but rather an ability acquired with training and perseverance: “<span class="elsevierStyleItalic">I have trained myself to see what others overlook</span>” (A Case of Identity, p. 341).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Careful listening</span><p id="par0045" class="elsevierStylePara elsevierViewall">One of the more instructive aspects of Holmes is his ability to listen with interest, without ever giving the feeling of haste, questioning when he considers it appropriate to understand the magnitude of the problem and clarify the temporal sequence of events: “<span class="elsevierStyleItalic">Holmes listened attentively to everything, throwing in a question from time to time</span>” (The Adventure of the Cardboard Box, p. 901). His method emphasizes how a detailed exposition of the facts, by the victim or witness, is crucial for the resolution of the puzzle: “<span class="elsevierStyleItalic">I want you to tell my friend your very interesting experience exactly as you have told it to me, or with more detail if possible. It will be of use to me to hear the succession of events again</span>” (The Stockbroker's Clerk, p. 849).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Knowing that someone has listened to you carefully creates a climate of trust that enables the speaker to provide relevant information: “<span class="elsevierStyleItalic">Sherlock Holmes was a past-master in the art of putting a humble witness at his ease, and very soon, in the privacy of Godfrey Staunton's abandoned room, he had extracted all that the porter had to tell</span>” (The Adventure of the Missing Three-Quarter, p. 1195).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although current movies and television series present a histrionic and almost marginal Holmes, nothing could be further from the truth. His treatment is exquisite, and in each novel he gives us practical lessons in how to generate empathy: “<span class="elsevierStyleItalic">You’ll get results, Inspector, by always putting yourself in the other fellow's place, and thinking what you would do yourself. It takes some imagination, but it pays.</span>” (The Adventure of the Retired Colourman, p. 1286).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Deductive reasoning</span><p id="par0060" class="elsevierStylePara elsevierViewall">With the initial data, a multitude of hypotheses emerge, which then enter a rapid process of selection that rules out many and strengthens only a few: “<span class="elsevierStyleItalic">From long habit the train of thoughts ran so swiftly through my mind, that I arrived at the conclusion without being conscious of intermediate steps. There were such steps, however … The whole train of thought did not occupy a second</span>” (A Study in Scarlet, p. 67).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The Holmes method highlights the importance of devoting time to reflect, consider the reasons and analyze the relevance of each fact, because it is the mind of the investigator that orders the information and directs the course of the investigation: “<span class="elsevierStyleItalic">I knew that seclusion and solitude were very necessary for my friend in those hours of intense mental concentration during which he weighed every particle of evidence, constructed alternative theories, balanced one against the other, and made up his mind as to which points were essential and which immaterial</span>” (The Hound of the Baskervilles, p. 687).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Another pathway used by Holmes for solving puzzles consists of contrasting the current problem with other similar puzzles known from experience and study: “<span class="elsevierStyleItalic">As a rule, when I have heard some slight indication of the course of events, I am able to guide myself by the thousands of other similar cases which occur to my memory</span>” (The Red-Headed League, p. 356). Thus, several episodes highlight the need for devoting time to study and reading. In this respect, his conversation with inspector MacDonald, a young Scotland Yard detective, is illustrative:<span class="elsevierStyleDisplayedQuote" id="dsq0015"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">“Have you ever read of Jonathan Wild?</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Well, the name has a familiar sound. Someone in a novel, was he not? I don’t take much stock of detectives in novels…</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Jonathan Wild wasn’t a detective, and he wasn’t in a novel. He was a master criminal, and he lived last century—1750 or thereabouts</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Then he's no use to me. I’m a practical man.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Mr. Mac, the most practical thing that you ever did in your life would be to shut yourself up for three months and read twelve hours a day at the annals of crime” (The Valley of Fear, pp. 419–420).</p></span></p><p id="par0075" class="elsevierStylePara elsevierViewall">Among Holmes’ numerous lessons on reasoning, there are three very useful ones for resolving complex problems:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0080" class="elsevierStylePara elsevierViewall">In addition to the main suspicion, always have alternative hypotheses: “We all learn by experience, and your lesson this time is that you should never lose sight of the alternative. You were so absorbed in young Neligan that you could not spare a thought to Patrick Cairns, the true murderer of Peter Carey” (The Adventure of Black Peter, p. 1115).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Detect the inconsistencies: assess the importance that the absence of an expected fact can have when proving or disproving a hypothesis:</p></li></ul><span class="elsevierStyleDisplayedQuote" id="dsq0020"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">“there any point to which you would wish to draw my attention?”</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">“To the curious incident of the dog in the night-time.”</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">“The dog did nothing in the night-time.”</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">“That was the curious incident,” remarked Sherlock Holmes” (Silver Blaze, p. 988).</p></span><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Discuss the most complex cases with others, because explaining the cases to others requires a mental exercise that is often highly illuminating: “<span class="elsevierStyleItalic">At least I have got a grip of the essential facts of the case. I shall enumerate them to you, for nothing clears up a case so much as stating it to another person</span>” (Silver Blaze, p. 972).</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Verifying the hypothesis: the careful examination</span><p id="par0095" class="elsevierStylePara elsevierViewall">Once the main hypothesis and its alternatives have been created, Holmes travels to the location of the events in order to perform a thorough and systematic examination in which he once again exercises his powers of observation and deduction: “<span class="elsevierStyleItalic">Sherlock Holmes … took possession of the dining-room … and devoted himself for two hours to one of those minute and laborious investigations which form the solid basis on which his brilliant edifices of deduction were reared. … The window, the curtains, the carpet, the chair, the rope—each in turn was minutely examined and duly pondered</span>” (The Adventure of the Abbey Grange, p. 1221).</p><p id="par0100" class="elsevierStylePara elsevierViewall">In his opinion, most criminals leave signs, which subtle as they are, reveal the nature of the guilty party and the way in which the events unfolded. Conversation with inspector Hopkins explains it thusly:<span class="elsevierStyleDisplayedQuote" id="dsq0025"><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">“I know your methods, sir, and I applied them. I examined most carefully the ground outside, and also the floor of the room. There were no footmarks.”</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">“Meaning that you saw none?”</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">“I assure you, sir, that there were none.”</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">“My good Hopkins, I have investigated many crimes, but I have never yet seen one which was committed by a flying creature. As long as the criminal remains upon two legs so long must there be some indentation, some abrasion, some trifling displacement which can be detected by the scientific searcher” (The Adventure of Black Peter, p. 1105).</p></span></p><p id="par0105" class="elsevierStylePara elsevierViewall">The examination of the scene of the crime is never routine or anodyne but rather an illuminating activity that contextualizes and contrasts the information received: “<span class="elsevierStyleItalic">I shall take nothing for granted until I have the opportunity of looking personally into it</span>” (The Boscombe Valley Mystery, p. 826). Thus, when Holmes visits the site of the events, he does so knowing what to look for, with the intent to find data that he lacks to confirm his working hypothesis: “<span class="elsevierStyleItalic">Holmes took the bag … then stretching himself upon his face and leaning his chin upon his hands, he made a careful study of the trampled mud in front of him.</span><span class="elsevierStyleDisplayedQuote" id="dsq0030"><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">“Hullo!” said he, suddenly. “What's this?”</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">It was a half burned wax vesta, which was so coated with mud that it looked at first like a little chip of wood.</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">“I cannot think how I came to overlook it,” said the Inspector, with an expression of annoyance.</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">“It was invisible, buried in the mud. I only saw it because I was looking for it” (Silver Blaze, p. 981).</p></span></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Usefulness of the Holmes method for resolving clinical problems</span><p id="par0110" class="elsevierStylePara elsevierViewall">Sherlock Holmes is a fictional character whose unique capacity for deduction was inspired by an actual person: Dr. Joseph Bell, Conan Doyle's professor at the faculty of medicine in Edinburgh.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It is therefore not surprising that several authors have found close parallels between clinical reasoning and the Holmes method.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> The case studies resolved using the Holmes method have been published,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> and a number of authors have recommended reading the complete works of Sherlock Holmes and teaching his method to students and residents.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,8,9</span></a> The same Conan Doyle compared both tasks when a customer told Holmes: “<span class="elsevierStyleItalic">You’re like a surgeon who wants every symptom before he can give his diagnosis.</span><span class="elsevierStyleDisplayedQuote" id="dsq0035"><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">“Exactly. That expresses it. And it is only a patient who has an object in deceiving his surgeon who would conceal the facts of his case” (The Problem of Thor Bridge, p. 1330).</p></span></p><p id="par0115" class="elsevierStylePara elsevierViewall">As can be easily deduced from all of the above, the <span class="elsevierStyleItalic">Holmes</span> method highlights the development of basic clinical skills, including the capacity for listening when conducting a review of a patient's medical history, a careful observation and a detailed examination, which still have magnificent diagnostic cost-effectiveness.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–12</span></a> There is a long tradition in our country of internists with excellent clinical and humanistic training, which has highlighted how physicians should “<span class="elsevierStyleItalic">always listen and observe even the smallest of details</span>”.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The Holmes method encourages the clinician to reason, contextualize information, search for the reasons, formulate and test hypotheses, unencumbered by the initial impression: “<span class="elsevierStyleItalic">the first thing I learned is to not be encumbered by an immediate and intuitive impression, but rather that this should be subsequently confirmed</span>”.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The eagerness to confirm the main hypothesis and test the alternatives will be the reason for which the clinician decides “<span class="elsevierStyleItalic">what analysis and tests are needed, and, if necessary, requested from the most simple to most complex</span>”,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> never searching for a shortcut to arrive at a diagnosis that, in the worst of cases, has not even been suggested.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> “<span class="elsevierStyleItalic">It is essential that the additional examinations deserve this qualifier and constitute not the fundamental activity of the medical task but rather only the supplementation of a perfectly structured diagnostic process by virtue of the case history review and the physical examination. These conditions will only be met when they are directed towards testing or ruling out a previously formulated provisional diagnosis. We only find what we look for</span>”.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The Holmes method therefore has an extraordinary similarity to the “clinical method” as it has been communicated to several generations of doctors in our country: “<span class="elsevierStyleItalic">Good clinicians begin by establishing the initial diagnostic approach right from the moment of contact with the patient, given that age, gender and external appearance already make an initial impression on a good observer. These initial diagnostic hypotheses, obviously very unspecific, are altered with confirmations and rejections over the course of reviewing the case history and continues to develop in the clinician's mind during the physical examination</span>”.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The accuracy with which Doyle analyzes the processes of diagnostic reasoning is surprising. These processes have been confirmed by recent advances in cognitive science: deductive reasoning, pattern recognition, the analytical reasoning of cause and effect and the importance of study.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">One of the more outstanding characteristics of Sherlock Holmes, as with all those who are masters of their profession,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> is the ability to infect others with the enthusiasm and interest with which he approaches each new case: “<span class="elsevierStyleItalic">Indeed, apart from the nature of the investigation which my friend had on hand, there was something in his masterly grasp of a situation, and his keen, incisive reasoning, which made it a pleasure to me to study his system of work, and to follow the quick, subtle methods by which he disentangled the most inextricable mysteries</span>” (A Scandal in Bohemia, p. 291).</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Minimize the possibility for errors</span><p id="par0145" class="elsevierStylePara elsevierViewall">The Holmes method also provides us several keys for not making mistakes, because it considers each patient as a diagnostic challenge, which is a positive approach that helps maintain concentration and avoid omissions. It also helps fight boredom, which is the main cause of medical errors.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The advice of Holmes helps us avoid making verification errors that occur when the clinician is content with a premature closure of the case, without checking that everything fits, that there are no loose ends and that the diagnosis is solid: “<span class="elsevierStyleItalic">You really think that your solution must be correct?” asked Holmes.</span> “<span class="elsevierStyleItalic">Does your explanation cover every point?</span>” (The Adventure of Black Peter, p. 1113).</p><p id="par0155" class="elsevierStylePara elsevierViewall">His method also alerts us against the frequent deformation of clinical reasoning that has “the tendency to highlight data that supports our diagnostic hypothesis and ignore those that contradict it”.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> As Holmes would say: “You find yourself insensibly twisting [the facts] round to fit your theories” (The Adventure of Wisteria Lodge, p. 954).</p><p id="par0160" class="elsevierStylePara elsevierViewall">The essence of the Holmes method is contained in the advice, almost posthumous, of professor López de Letona written in an RCE article: “<span class="elsevierStyleItalic">Life has taught me that the immense majority of medical errors are due not to the difficulty of each case but rather to an ignored but obvious fact, either during the interview or during the physical examination</span>”.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The author declares that he has no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres329543" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec311427" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres329544" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec311428" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "The Holmes method" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Detailed observation" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Careful listening" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Deductive reasoning" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Verifying the hypothesis: the careful examination" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Usefulness of the Holmes method for resolving clinical problems" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Minimize the possibility for errors" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack78444" "titulo" => "Acknowledgements" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-03" "fechaAceptado" => "2013-11-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec311427" "palabras" => array:6 [ 0 => "Sherlock Holmes" 1 => "Physical examination" 2 => "Medical history" 3 => "Clinical method" 4 => "Teaching medicine" 5 => "Clinical skills" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec311428" "palabras" => array:6 [ 0 => "Sherlock Holmes" 1 => "Exploración física" 2 => "Historia clínica" 3 => "Método clínico" 4 => "Enseñanza de la medicina" 5 => "Habilidades clínicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This article lists the integral elements of the Sherlock Holmes method, which is based on the intelligent collection of information through detailed observation, careful listening and thorough examination. The information thus obtained is analyzed to develop the main and alternative hypotheses, which are shaped during the deductive process until the key leading to the solution is revealed. The Holmes investigative method applied to clinical practice highlights the advisability of having physicians reason through and seek out the causes of the disease with the data obtained from acute observation, a detailed review of the medical history and careful physical examination.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En este artículo se exponen los elementos integrantes del método de Sherlock Holmes, que está fundamentado en una recogida inteligente de información mediante la observación minuciosa, una escucha atenta y un examen detallado. Los datos, así obtenidos, son analizados para elaborar la hipótesis principal y las alternativas, que se van perfilando durante el proceso deductivo hasta dar con la clave que llevará a la solución del problema. El método de trabajo de Holmes, aplicado a la práctica clínica, destaca la conveniencia de que los médicos razonen y busquen las causas de la enfermedad con los datos obtenidos a partir de la observación aguda, de una historia clínica detallada y de una exploración física cuidadosa.</p>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sopeña B. El método de Sherlock Holmes en la práctica clínica. Rev Clin Esp. 2014;214:150–154.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The Spanish version of this manuscript took all Sherlock Holmes quotes from: Arthur Conan Doyle. Todo Sherlock Holmes. 3.ª edición, Barcelona: Bibliotheca Aurea. Barcelona: Editorial Cátedra; 2004. ISBN: 84-376-2034-1. The English translation used the Project Gutenberg (<a class="elsevierStyleInterRef" id="intr0010" href="http://www.gutenberg.org/ebooks/search/%3Fquery=sherlock+holmes">http://www.gutenberg.org/ebooks/search/?query=sherlock+holmes</a>). The page numbers provided reference the Spanish Todo Sherlock Holmes.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Joseph Bell (1837–1911): centenario del cirujano que inspiró a Arthur Conan Doyle el personaje de Sherlock Holmes, y que enseñó urología en Edimburgo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.A. 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