Why we should not comment on Hilliary ’ s “ pneumonia ” diagnosis
Often, as physicians, friends and families ask us about diagnoses and prognoses. We usually do not have adequate information to opine, yet we feel pressure to comment.
As I perused twitter yesterday, read newspaper articles this morning, and listened to commentary over the past 24 hours, I believe that we do not know enough to provide any commentary.
What does a diagnosis of “pneumonia” really mean? Are we considering community acquired pneumonia?
Questions that I would want to have answered:
A careful history of her symptoms – when did they start, is her cough productive, does she have a fever, any ...
Source: DB's Medical Rants - September 12, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 17 – Being positive
Yesterday on a plane I read Ellen Latham’s book Push. She founded Orangetheory Fitness. The book has a large portion of autobiography, telling the story of how she eventually developed the workout that became OTF.
A large part of her book surprised me. I expected a story about exercise, but interwoven in that story she champions positive coaching. She attributes this philosophy to her father.
When you go to OTF, the coaching is always positive. Coaches work to help you improve. They never denigrate.
And this is today’s lesson for IM Attendings. Our job involves coaching our learners. We want them ...
Source: DB's Medical Rants - September 9, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Physicians versus computers – the wrong question!!!
Over the past 2 days, listening to separate podcasts, I have heard the same story and now have a better understanding of artificial intelligence. A Freakonomics podcast – The Future (Probably) Isn’t as Scary as You Think
And in general, what’s happened in the past couple of years is the best chess player on this planet is not an AI. And it’s not a human. It’s the team that he calls centaurs; it’s the team of humans and AI. Because they’re complementary. Because AIs think differently than humans. And the same of the world’s best medical diagnostician is not Watson, it’s not a human doctor. It’s the...
Source: DB's Medical Rants - September 7, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Direct primary care – understand the appeal before your criticize
ACP has an excellent position paper on direct primary care – Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians
Martin Donohoe, MD in a letter criticizing the paper Academic Medicine and Concierge Practice makes what I consider the tired, holier than thou, ethical argument that such practices are in fact not ethical. He writes,
For such institutions to teach students to treat all patients equally, combat inequalities in health care access and outcomes, and practice evidence-based medicine while...
Source: DB's Medical Rants - September 6, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 16 – Why I like table rounds before bedside rounds
In a previous chapter, I noted that various styles can work well. Adopting a style and perfecting it are hallmarks of highly ranked and desired attending physicians. For 35 years I have developed a style that works. When other attendings try this style, it may or may not work. My learners often mention how valuable they find this style. Their feedback has helped my develop the key features of the style.
Any teaching style should develop from clearly defined goals. My teaching style directly follows from these principles:
We want each learner to understand each patient, their diagnoses and treatments.
We want t...
Source: DB's Medical Rants - August 29, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Health care costs – the big problems
Physicians often wonder in what reality we have the current health care cost problem. Contrast physician payments with the pharmaceutical industry.
As an internist with over 35 years experience, my payment schedule is exactly the same as a newly minted internist. Can anyone think of another profession that does not get some credit for experience and reputation?
Can anyone imagine a payment system that encourages you to spend less time with your patient, because you payment for a 15 minute visit is likely the same as a 20 minute visit? Can you consider the implications of a system that encourages volume rather than a...
Source: DB's Medical Rants - August 27, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
When too many cooks … the problem of too many consultants
Recently I communicated with a patient’s mother in another state. She had great angst when a series of subspecialists gave her different opinions on the ongoing plan for her grown son.
This problem happens too often in 2016. Each subspecialist seems to see the patient solely through the prism of their expertise. We have seen one consultant call 3 or 4 other consultants.
Many hospitalists will tell you this story. At many community hospitals the consultants do not just provide an opinion, but rather they write orders. This practice leads to confusion and sometimes conflict amongst the subspecialties.
Several...
Source: DB's Medical Rants - August 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Palliative care – our responsibility to patients
This week we had an all too common clinical situation. A patient with severe COPD developed pneumonia. His prognosis because of his underlying disease is relatively poor.
Fortunately, the patient and his wife had previously discussed resuscitation and intubation. He does not want to go down that road. Because of this conversation we quickly went down the road to palliative care.
As we explained to the patient and his wife, we will treat his pneumonia with appropriate antibiotics, but we will also treat him. Sometimes in medicine we forget the patient. We focus on the disease or the prevention of a disease. Bu...
Source: DB's Medical Rants - August 20, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 15 – Teaching the HPI
Students (and interns and residents) provide important insights into their skills and understanding with their oral presentation of the history of present illness (HPI). The history of present illness provides the key to diagnosis in a great majority of patients. A recitation of the history of present illness shows us how the learner has thought through the patient’s problem and their skill at asking the best followup questions.
Several years ago I heard this great description of the process of reporting the HPI. The first paragraph recounts the patient’s story in depth. This includes the patient’s chief comp...
Source: DB's Medical Rants - August 14, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Running faster thanks to @OTheoryFitness
3 years ago I started running as part of my weight loss program. Like many, running became addictive. Running makes me feel much better and healthier. As part of my running, I decided to compete in the occasional 5k (not interested in running longer distances).
I have a “big audacious goal” to run a 5k in less than 25 minutes. I have run a bit less than 27 minutes, but for 2 years I have felt stagnant.
When you read running magazines, you get several consistent tips, especially for older runners. One big problem we have as we age is stride length, and the other is strides per minute. As I read these...
Source: DB's Medical Rants - August 3, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 14 – Incorporating basic sciences
When we understand how things work and how they function in an impaired fashion, then we better remember testing and treatment. In internal medicine, when we understand the physiology and pathophysiology, then we often make better decisions.
Teaching from a physiologic viewpoint can challenge many attending physicians. We believe that investing in this approach has great worth.
Hyponatremia provides an excellent example. When we discuss hyponatremia, we must first understand that it represents a water problem – for some reason we are not excreting enough water. Then we understand how the kidney excretes water...
Source: DB's Medical Rants - July 25, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 13 – Understanding Laboratory Tests
We order many laboratory tests. Learners report laboratory tests regularly, but too often they lack a sophisticated understanding of their meaning.
Regularly a new student or intern reports that the labs are “unremarkable” (an unfortunate term). As a lover of lab test interpretation I cringe, especially when I look at the labs for clues. Excellent internists know that laboratory tests provide clues and those clues sometimes lead to answers.
The best attending physicians will study and learn how to interpret all the common tests and many of the less commonly ordered tests. Here is the good news, most learners ap...
Source: DB's Medical Rants - July 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 12 – Preparing teaching chunks
Many concepts recur often in medicine. Patients get admitted for syncope, or chest pain, or edema. Patients have anemia, or hyponatremia or hypokalemia. We could make a long list of relatively common situations that we see repeatedly as attending physicians.
Our learners need to develop a thoughtful approach to each of those situations. As an educator you should develop a series of learning chunks for many situations. For example, a patient gets admitted to our service with syncope. Here is a rough outline of my approach, understanding that each number represents a chunk for teaching and learning:
Is it really...
Source: DB's Medical Rants - July 23, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 11 – Question & rescue
Many authors condemn “pimping”, yet most learners appreciate questioning as a teaching technique. How can we reconcile these two concepts?
Those who condemn pimping define pimping as questioning with embarrassment and humiliation. Since that term can carry a negative connotation, we need to use a new label.
I ask questions constantly on rounds and in morning reports. As attending physicians, we should ask questions, but we should not put the learner in such a vulnerable position that they feel insulted and embarrassed. So these two techniques make questioning help the learners.
First, question and rescue. Ask a questio...
Source: DB's Medical Rants - July 22, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 10 – Repetition
As a resident, I prepared a number of “chalk talks”. They were (at least in my mind) brilliant. I wowed the students and interns. But I never checked to see if they learned the topic.
As attending physicians our goal should involve learners’ learning the material, which differs from “brilliant teaching”. How do we induce learning?
Repetition helps learners absorb the material. As an educator it may seem boring or a waste of time to focus on repetition. But we teach not to look smart, but rather to transfer understanding. A brief anecdote may help.
Several years ago the house staff presented a patient at morning r...
Source: DB's Medical Rants - July 21, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
