The work hours conundrum – focus on the work rather than the hours
This study does not resolve our feelings. What it does tell us is that patients do not appear to suffer when residents work longer hours. (Source: DB's Medical Rants)
Source: DB's Medical Rants - February 4, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Consequences & why the train leaving the station means nothing
I read and listen to much fiction. While listening to a fantasy novel, one character verbalizes a most important concept. Every action has consequences. Those consequences are both expected and unexpected. We might predict some unexpected consequences, if we only spend some time to think through the likely impact of that action.
Bureaucrats and politicians have imposed a series of administrative burdens on physicians and patients. We use EHRs that work slowly and non-intuitively. We are forced to write notes that do not make medical sense, lead to inferior communication and emphasize all the work components of ...
Source: DB's Medical Rants - February 1, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Teaching the thought process – some thoughts
I often write about teaching the thought process. Research that we (multiple clinician educators at UAB) have published documents clearly that learners value attending physicians who teach the thought process. Learning this was a bit of a surprise to me, but many students and residents have reinforced this concept in conversations over recent years.
These words are easy to type, but how does one learn to teach the thought process. In thinking about this, I have an idea, and would love to read your comments about this suggestion.
Two days ago in morning report we had a patient with possible syncope. If you are teach...
Source: DB's Medical Rants - January 28, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The answer – hypokalemic metabolic alkalosis and hypocalcemia
To recap the story:
70+ year old man with recent admission for pneumonia. Discharge on clindamycin and levofloxacin. Now with progressive weakness, fatigue, tingling and confusion.
142
98
12
256
2.5
32
1.4
6.5
albumin 2.8
pH 7.53
pCO2 39
pO2 69
HCO3 32
What happened in the past 3 weeks? What diagnostic tests do you want, and what questions do you want to ask?
Answer:
He had some loose stools, but negative C diff.
I asked the question about his previous labs – they had been normal. Hypokalemic metabolic alkalosis and hypocalcemia made me think of hypomagnesemia. Then I wondered why he would have low ...
Source: DB's Medical Rants - January 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Acid-Base & Lytes Attending Rounds Source Type: blogs
Pimping or grilling – students generally like being asked questions
My colleagues and I ask students and residents questions constantly. I talk with students and residents constantly about their educational experiences. The great majority like being asked good questions.
But what is a good question? A good question refers to something that they need to know. The good question frames the importance of the topic. A bad question is pure trivia that will not really help them (what percent of alcoholic ketacidosis patients have a negative urine ketone – the answer is approximately 10%). Knowing that some AKA patients have negative ketones and why is useful.
Additionally, to as...
Source: DB's Medical Rants - January 22, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tingling, weakness, fatigue and abnormal labs
70+ year old man with recent admission for pneumonia. Discharge on clindamycin and levofloxacin. Now with progressive weakness, fatigue, tingling and confusion.
142
98
12
256
2.5
32
1.4
6.5
albumin 2.8
pH 7.53
pCO2 39
pO2 69
HCO3 32
What happened in the past 3 weeks? What diagnostic tests do you want, and what questions do you want to ask?
(Source: DB's Medical Rants)
Source: DB's Medical Rants - January 21, 2016 Category: Internal Medicine Authors: rcentor Tags: Acid-Base & Lytes Attending Rounds Source Type: blogs
The Value Tension
I spent this past weekend discussing internal medicine’s future with colleagues. We spent our time forecasting, predicting and prioritizing. During those discussions the concept of the value tension evolved.
So why is the definition of value so important to internal medicine (and all other medical fields). The MACRA website:
The MACRA will help us to move more quickly toward our goal of paying for value and better care. It also makes it easier for more health care providers to successfully take part in our quality programs …
One might assume that value is easy to define. Congress must believe that we c...
Source: DB's Medical Rants - January 19, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Performance measurement – we welcome the recent critics
I first wrote about my concerns over 10 years ago. In those early days of the blogosphere, few experts paid attention to ou ranting.
Just over 10 years ago I wrote
One underlying principle of the pay for performance movement stems from the belief that we can use incentives to improve adherence to evidence based quality indicators. The crux of evidence based medicine (EBM) follows from an examination of high quality data. EBM eschews belief. – See more at: http://www.medrants.com/archives/2549
This week two more Bobs (Wachter & Berenson) wrote eloquently about the problems of P4P
How Measurement Fails Doctors an...
Source: DB's Medical Rants - January 17, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
On maintaining weight loss
Alex Hutchinson who writes a wonderful column in Runner’s World (Sweat Science) provided a very interesting column that relates to weight loss maintenance. We know that exercise can help with weight loss, but that you must also eat more carefully. This column – the Jute Diet – explains why exercise makes weight maintenance easier.
What you see is that, above a certain level of physical activity, caloric intake increases linearly and weight is stable. For these workers, the body’s “balance” mechanism is functioning, and those who burn more calories also consume proportionately more calories.
But ...
Source: DB's Medical Rants - January 10, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Concussion – why we should remain skeptical
This past weekend I saw Concussion. The movie, while well done, left me conflicted as a scientist. As I often do after seeing movies based on true stories, I searched the internet for a good commentary. I found this article – Concussion Lies.
I suspect this article has significant biases, however, we should all remain skeptical because the science described in the movie involves correlation rather than causation. Dr. Omalu discovered a pathological finding associated with football players. He studied football players who had committed suicide or died in other violent ways. He then made a cognitive leap a...
Source: DB's Medical Rants - January 7, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Orange Theory Fitness – @OTheoryFitness – variety works
This past Labor Day weekend, my daughter asked me to do a workout at OTF. I doubt that anyone else could have convinced me to not play golf that Sunday, but when your daughter asks, you go to check out her new workout passion. I had not previously done group training, but her description sounded attractive.
As I reminded readers yesterday, exercise has become a major obsession over the past 2 1/2 years. I run, do some resistance training, and walk a great deal. I had worked with a private trainer, but those sessions (albeit productive) got stale. At times my running becomes stale. While I was exercising regular...
Source: DB's Medical Rants - January 3, 2016 Category: Internal Medicine Authors: rcentor Tags: Fitness & weight Source Type: blogs
Resolutions – no major changes
Each year many Americans make New Year’s Resolutions. Few keep them. Each January the gyms get much more crowded, and the number of new faces astounds the regulars.
Over the year’s I have made resolutions, and often failed. Memorial Day weekend 2013, I started a weight loss project. I wrote these words 7 weeks after starting:
One day a couple of months ago, I realized that I was working on weight loss. No resolutions, no epiphanies, no health scares stimulated my project. I just slowly decided that I would feel better if I decreased my weight. I am losing 1-2 pounds per week, and hope to continue ...
Source: DB's Medical Rants - January 2, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Multitasking and not taking time to think
How could a blog post titled Learn how to think avoid my praise? This post made the Farnam Street Blog top 10 for 2015. The post refers to a wonderful essay – Solitude and Leadership By William Deresiewicz. On first reading (and this essay deserves several reads) two concepts resonated strongly.
Multitasking, in short, is not only not thinking, it impairs your ability to think. Thinking means concentrating on one thing long enough to develop an idea about it.
We know that multitasking does not really work. This concept has great importance in medicine. We have added so many tasks to the patient interacti...
Source: DB's Medical Rants - December 31, 2015 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Trending issues in medicine – issues bubbling below the top 5
One can easily criticize the 5 issues I picked this year. I could criticize myself. Here are some other important issues that we should consider.
Pharmaceutical pricing greed – The concept of capitalism should not excuse the outrageous pricing of many new (and some older) drugs. Pharmaceutical companies get a patient monopoly for 20 years from the time of patent application. A great discussion of the problem.
Medical school tuition – our students incur extremely large debts to finish medical school (in addition to undergraduate debt). Talk to 4th year medical students, and their debt significantly i...
Source: DB's Medical Rants - December 29, 2015 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Trending issues in medicine 2015 – #1 Burnout
This report provides more evidence of the importance of these factors, with bureaucratic tasks and spending too many hours at work rated as the most frequent causes of burnout, with scores of 4.74 and 3.99, respectively, based on a scale of 1 (“not at all important”) to 7 (“extremely important”). In fact, being able to control work hours is increasingly found to play an important role in reducing stress and, therefore, burnout among physicians.[7-9] This year, insufficient income (3.71) and computerization (3.68) were also found to be important causes of burnout. One study found that PCPs with the h...
Source: DB's Medical Rants - December 28, 2015 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
