My tweetorial collection
You can probably tell that I tweet much more than I write blog posts these days. I have started doing tweetorials – linked collections of tweets that tell a story. Most tweetorials represent teaching or rather online chalk talks.
They are now being collected (along with other tweetorials that I particularly like and want to use. Here is the link: Medrants Tweetorials
If you do not follow me on twitter or use twitter, you can still use this link to read through these teaching sessions. (Source: DB's Medical Rants)
Source: DB's Medical Rants - March 3, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The man in 558
Coming in to meet the students, housestaff and patients for the first day on service always excites me. This Monday was no exception. What awaited me? How many patients would I need to see? What lessons could I impart?
When I arrived we had 11 patients, 2 new and 9 had arrived previously. Going through the list, while routine, always stimulated questions and teaching opportunities. Sometimes the team had questions for me. Sometimes they had a mischievous sense of putting me on the spot. I always love that interplay.
When we got to the man in 558, they told a sad story of an angry man with terminal cancer. He had acc...
Source: DB's Medical Rants - February 25, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Reflections on risk prediction
This Monday evening our next podcast becomes available. Dr. Gustavo Heudebert and I discuss another article about risk prediction. This topic has become a recurring theme on the Annals On Call podcast.
Why is risk prediction so important? In 2019 we make many decisions about prevention and testing based on risk prediction. In addition we also estimate harms and benefits. All these predictive models have advantages and flaws. In making a decision for statin use (another upcoming episode), we have to estimate the risk of cardiovascular events, how much taking a statin will decrease that risk, and the probability and type...
Source: DB's Medical Rants - February 16, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Reflections on my social media Grand Rounds
Over the past 2 days, after participating in Grand Rounds, I did what I always do after giving a talk. I replayed the process in my head, and tried to understand what I had done well and not as well. But this time, given the new topic, my reflections shed some light on my use of social media and the importance of the “big experiment” of Skyping with Dr. Matt Watto to discuss podcasting.
My first understanding was that blogging has mostly served me. It has given me a platform to become a better writer. But more important it has allowed me to put my ideas down on paper. This process allows me to test out ideas...
Source: DB's Medical Rants - January 25, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Penicillin allergy, probably not
The current issue of JAMA has a wonderful review of penicillin allergy. This conclusion is important:
Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other ?-lactam antibiotics is an important tool for antimicrobial stewardship.
This concept has great importance. Almost every time I give a pharyngitis talk, someone asks me about second-line antibiotics for patients with “penicillin allergy”. Since penicillin (or amoxicillin) work well against group A strep, group C/G strep and Fus...
Source: DB's Medical Rants - January 20, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
2018 #reflection – another great year
In 3 weeks I will present a Grand Rounds talk on social media and internal medicine. If you had asked me if this would be a possibility when I started blogging in 2002, I would have laughed.
My social media resolution this year was to post on twitter every day with the #5goodminutes . I succeeded. What have I learned?
Having finished my residency 40 years ago, I still love internal medicine. I learned much new this year. Putting some pressure on myself to find something worthwhile to post each day forced me to read more. As usual, our learners continue to push me to become a better physician and educator.
So #medt...
Source: DB's Medical Rants - December 31, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
If I were writing sore throat guidelines
Several tweets asked me to answer this question. How would I rewrite sore throat guidelines? Obviously I am biased. So this is my opinion and I am sticking to it!
I would not change anything about pre-adolescents. Group A strep is the most important bacterial infection and using rapid tests with backup cultures makes sense.I would change the guidelines for adolescents and young adults. I would treat patients having Centor scores of 3 or 4 with either penicillin or amoxicillin (augmentin would be fine). I would probably treat some 2s if they looked very ill. I would never use macrolides. If the patient is truly penicilli...
Source: DB's Medical Rants - December 29, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
More evidence on suppurative complications from Fusobacterium necrophorum tonsillitis
This study adds to our clinical understanding of the devastating potential of this gram negative anaerobic bacteria. We have previously found that FN pharyngitis has the same clinical presentation as strep pharyngitis. Our microbiome study showed that patients with more severe clinical pharyngitis (defined as Centor scores of 3 or 4) differed between group A strep and Fusobacterium necrophorum. The tonsils with FN infection had a less bacterial diversity – this means that FN overwhelms the microbiome in many such patients.
These findings suggest that FN more likely causes suppurative complications. We know from th...
Source: DB's Medical Rants - December 29, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The neverending story – unintended consequences
This article points out the unintended consequence of this regulations – LOWER READMISSIONS LINKED TO HIGHER RISK OF DEATH
Regulators and insurance companies are impacting patient care through their well-intended rules. They do not seem think deeply about their rules. If they would use premortem examinations, perhaps we would have less of these problems. I wrote about this 2 years ago – Incentives without forethought
The continued problem of unintended consequences is one that many medical societies have addressed. I am most familiar with ACP. Their current Patients before Paperwork initiative makes many ...
Source: DB's Medical Rants - December 26, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Acid-base and Electrolyte thoughts from Core IM Episode #14
Listening to Episode #14 of Core IM, I imagined discussing this case at VA morning report. For the past 20+ years, each month we have one session in which the chief residents present me acid-base &/or electrolyte cases to dissect. My discussion of this case is different from the podcast. That statement should not surprise anyone. This patient story lends itself to various discussions. I hope this blog post is complementary to the podcast.
The presentation of quadriparesis immediately made me consider severe hypokalemia. The patient had no trauma and did not have the classic GB story. Perhaps I lean to severe hypokal...
Source: DB's Medical Rants - December 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
On podcasting
FOAMed – Free Online Access Medical Education
This includes blogs, tweets (especially tweet chats and tweetorials) and podcasts. Over the past 3 years I became fascinated with podcasts. Originally, I listened to non-medical podcasts – Freakonomics, Lexicon Valley, Revisionist History and the Knowledge Project. I listened to a few medical podcasts, but too many were boring.
Over the past 2 years, medical podcasting has emerged as a viable way for me to do my personal continuing education. Until recently, I did not get any CME points, but really did not care. For me continuing education is a reward in itsel...
Source: DB's Medical Rants - December 22, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The value of schema
Our research and anecdotal experience both tell us that our learners are most interested in our thought processes. I have used schema for years, but never had the right name for that process. Dr. Reza Manesh, in the latest episode of the Curbsiders, uses a schema to help diagnose an unknown patient. He defines it:
Diagnostic Schema
A systematic way to tackle a clinical problem by having an organized approach.
On reflection I realized that this is major tool for my teaching. I have teaching schema for chest pain, syncope, hyponatremia, etc. I wrote about my chest pain schema in 2006!
7 deadly causes of chest pain ...
Source: DB's Medical Rants - November 24, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The scope of diagnosis – some thoughts after attending #DEM2018
This past weekend I participated in the Society to Improve Medical Diagnosis annual meeting. I saw many old and new friends. Going to a meeting often stimulates thinking. Because we often talk about diagnostic errors, we must first define diagnosis. As I listened to talks, observed posters, and talked with colleagues a broader concept occurred. Probably others have considered this, and if so, please send me the reference.
Diagnosis has several levels. A patient coming to see either a primary care physician, cardiologist, emergency physician or someone else (including urgent care, nurse practitioners, and physic...
Source: DB's Medical Rants - November 8, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Thoughts on a 23-year-old athlete dying from the Lemierre Syndrome
K-State football team to honor rower Samantha Scott, who died of Lemierre’s Syndrome
Every time I read such a story my heart breaks, a small piece each time. More physicians have become aware of the Lemierre syndrome. We must also educate patients and families that sore throats in adolescents and young adults can become life threatening.
Why did she die? The article does not have enough detail to develop a firm conclusion. I can speculate on several reasons from multiple discussions with both survivors and families of adolescents who died. We also have some unpublished survey data that informs my speculations.
Wh...
Source: DB's Medical Rants - November 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Yes, price matters
Two articles in the NY Times Health section today reinforce a major message from a recent Annals On Call: Oral Pharmacologic Therapy in Type 2 Diabetes: Choosing Therapy Wisely (Podcast with Dr. Mike Barry) – price matters.
The first article – Amgen Slashes the Price of a Promising Cholesterol Drug refers to their PCSK9 inhibitor.
For years, the drug maker Amgen has struggled to sell its new anti-cholesterol drug, Repatha after insurers balked over the list price of about $14,000 a year.
On Wednesday, Amgen took a new approach: It said it would slash the list price to $5,850 a year in hopes of increasing sales...
Source: DB's Medical Rants - October 26, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
