The challenge of “ evidence based ” sore throat guidelines
CONCLUSION Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community.
We assume that the word “evidence” is all inclusive. How can 9 guidelines on one subject differ significantly? The first problem occurs in selecting the evidence. Like ...
Source: DB's Medical Rants - October 23, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Role models in #meded
In the 70s when I trained, we had no add-on curricula; we had no milestones; we had little interference from governing bodies. What we did have was role models.
In the current century, when I talk with students and residents (and I do that very often) they talk about what they see or do not see from their attending physicians and fellow residents. The carefully constructed curricula result from excellent intentions, but role models defeat those curricula every time.
If we want our learners to show respect for diverse patients; if we want our learners to understand the struggle that many patients have with drug costs; i...
Source: DB's Medical Rants - October 22, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM ward attendings – Chapter 19 – the attending as coach #meded
Today I have been listening to a podcast featuring a boxer. This boxer discusses coaching and its importance.
Anyone who has competed in a sport can relate to the importance of accurate coaching. Coaching requires immediate feedback, both positive and negative. The feedback works best when you receive it immediately after you perform.
What do learners tell us? They want feedback, specifically feedback on how to improve. Therefore, during clinical teaching we owe our learners clear actionable feedback.
The first thing we should do is explain that we are giving feedback. Many years ago, I thought I was giving fee...
Source: DB's Medical Rants - October 16, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The adverse consequences of premature diagnosis
I have spent 3 days at the Society to Improve Diagnosis in Medicine. Whenever I come to this meeting, I have insights from listening to talks and many conversations with leaders in the field.
When one considers diagnostic errors, one must consider two important factors – physician factors and system factors. We have a major system factor that can cause problems. Most hospitals in the US require a diagnosis for admission. I believe this rule increases diagnostic errors.
Currently I am developing a talk based on the lessons we can learn from fictional detectives. One example that I will likely use came from a...
Source: DB's Medical Rants - October 10, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Recognizing the wonderful clinician educators
When asked to describe my career, I consider myself primarily a clinician educator. Recently I have reflected on the influences that allowed me to have a successful career doing what I love. This post is not meant to mention all those influencers, but just some that I recall often. As I have thought about this post, I quickly realized that all the “heroes” that I recall focused on clinical education. Students and residents show great respect and love for the great clinician educators, while too often these same clinician educators get less respect from medical school administration.
When I started my 3r...
Source: DB's Medical Rants - October 9, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The responsibility to prioritize
Each day when we work with patients, we prioritize their concerns, their diseases, and their economic situation. Our patients often have great complexity and we cannot address every problem during at one time. We must prioritize their problems and address the most urgent, perhaps spending less energy on the least urgent.
But who determines urgency; who determines priorities. Too often computer pop-ups direct priorities. Too often we are urged to turn our attention to an algorithm defined priority rather than a patient defined priority.
So the first need for prioritization comes in our responsibility to the individu...
Source: DB's Medical Rants - September 29, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Exercise, a purpose statement
Regular readers know of my exercise addiction. As a 68-year-old man, what drives me to improve my cardiovascular and strength conditioning? An interesting running podcast, Rogue Running, poses a challenge for runners that they train. Write down your statement of purpose for running. The trainers argue that until you commit to your purpose, then your training lacks appropriate focus.
I am fortunate to have good health. Any physician understands that fortune. Four years ago I lost 40 pounds, and now I have a BMI < 25.
For a couple of years I ran regularly and occasionally did strength training. As readers kn...
Source: DB's Medical Rants - September 19, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Ban the term productivity from medical care
According to Wikepedia:
Productivity describes various measures of the efficiency of production. A productivity measure is expressed as the ratio of output to inputs used in a production process, i.e. output per unit of input. Productivity is a crucial factor in production performance of firms and nations.
Please tell me how this relates to being a physician or a patient. We do not produce anything. Rather we work with individuals to diagnosis, prevent, treat, and hopefully improve both longevity and quality of life.
Physicians work with individual patients. We should strive to tailor care with our patient.
Productiv...
Source: DB's Medical Rants - September 18, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Rekindling the Joy of Medicine – thoughts after Dr. Kelley Skeff ’ s Grand Rounds
Yesterday, we had the treat of hosting Dr. Kelley Skeff for our 7th Research and Innovation in Medical Education Week at UAB. He gave a brilliant Grand Rounds that I hope everyone will get a chance to hear. He talked about the Joy of Medicine and the threats to that Joy.
Readers of this blog would find much of his talk familiar. Of course he told the story extremely well.
He focused on why we should be joyful in medicine, and then proceeded to talk about the artificial barriers to our joy. He made us think.
Kelley has dedicated his career to teaching medicine and teaching the teachers how to teach better. I am on...
Source: DB's Medical Rants - September 14, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Where did diagnosis education go, and why?
This article in the Annals of Internal Medicine echoes many blog posts – Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training The article ends with this paragraph:
As we strive to ensure that the diagnostic process receives the attention it deserves in our internal medicine training programs, we must look to the challenges that have resulted in our shift of focus and work to provide solutions that return this art form to the forefront of our training models. We need to build time for trainees to develop curiosity without constraint, rewarding the diagnostic reasoning process and looking to co...
Source: DB's Medical Rants - September 12, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
2 years of Orange Theory Fitness – impacts and lessons learned
2 years ago this weekend, my wonderful daughter asked me to check out OTF with her. She had started going ot OTF in her home town, and was visiting for Labor Day Weekend. At the time I was running, had already lost almost 40 pounds, but was doing minimal variety in my workouts.
I like it immediately, but because of an extremely busy travel schedule did not have time to get serious for several months. I would go about twice a week, and looked forward to each session.
After around 4 months I became an unlimited member, and have probably averaged 4-5 sessions per week. As I began going more frequently, I had a learnin...
Source: DB's Medical Rants - September 3, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Patients need more time with their physicians; Physicians need more time with their patients
This article comes from Great Britain and their wonderful NHS. It is slightly less bad in the USA. Electronic health records have worsened the problem because charting takes much longer.
Many experts believe that inadequate time leads to diagnostic errors. Others (as the article suggests) note that shared decision making takes time, and too often we do not have adequate time to have those discussions.
We waste resources trying to cram too many patients into the physicians day. We cannot say this often enough. This is not a doctor issue; this is a patient issue. Patients suffer when we shorten their visits.
&nbs...
Source: DB's Medical Rants - August 30, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Podcasting with the Curbsiders – please listen!
I just had the great honor of being a repeat guest for the Curbsiders. Published today, we discuss #54: Upper Respiratory Infections: Coughs, colds, gargling, and antibiotic underuse?!
Regular readers can probably imagine my comments. I mostly focused attention on defining when upper respiratory infections are not routine. As I have written previously, while we do not want to prescribe unnecessary antibiotics, we also do not want to withhold necessary antibiotics. My concern with most guidelines and algorithms is the lack of specificity in defining routine bronchitis, sinusitis or pharyngitis in the context of the ...
Source: DB's Medical Rants - August 28, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Defeating the implicit curriculum that discourages family medicine
This past February I retired as Regional Dean after 12.5 years. Our regional campus at the time had 25 3rd & 4th year students. Over the years we increased to 35 per year. Our campus has had a family medicine residency for over 40 years now. Yet, when I started, we did not have many students enter family medicine.
Prior to becoming a regional dean, I worked at large academic medical campuses. Any student interested in family medicine residency runs into persistent insults and harassment. When you talk to these students, they point fingers at residents in almost every speciality. Many attending physicians ...
Source: DB's Medical Rants - August 23, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
How would one rate physicians – the implications of multidimensionality?
Ratings have become a national obsession. US News & World Report rates colleges, medical schools, hospitals, subspecialties, etc. Some private firms develop physician ratings. Many insurance companies provide physician report cards. Intuitively most physicians understand that these ratings have serious flaws, yet they persist.
H/T to Atul Grover
who tweeted a Malcolm Gladwell article that I had read and forgotten – The Order of Things: What college rankings really tell us.
A ranking can be heterogeneous, in other words, as long as it doesn’t try to be too comprehensive. And it can be comprehensive a...
Source: DB's Medical Rants - August 14, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
