Diagnostic errors in 2017 (part 2)
This study raises some interesting questions and suggests some interesting new avenues of thought. (Source: DB's Medical Rants)
Source: DB's Medical Rants - August 14, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Thoughts on diagnostic errors in 2017
The Society to Improve Diagnosis in Medicine has on its website this quote:
Reducing Harm from Diagnostic Error
1 in 10 diagnoses are incorrect.
Diagnostic error accounts for 40,000-80,000 US deaths annually—somewhere between breast cancer and diabetes.
Chances are, we will all experience diagnostic error in our lifetime.
(US Institute of Medicine 2015, BMJ Quality & Safety 25-Year Summary of US Malpractice Claims, 2013.)
The current focus on diagnostic error raises an interesting question: Is this a larger problem in 2017 than in the 1970s and 1980s?
In this post, I postulate that the problem has increased. Se...
Source: DB's Medical Rants - August 7, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Are we developing the next generation of diagnosticians?
A senior consultant lamented to a colleague that he worried about the future of diagnosticians. Diagnostician once described the epitome of internal medicine. You could not give an internist a greater compliment. But this consultant felt (whether he was right or wrong is unclear) that too often our younger colleagues lack diagnostic curiosity.
This question is legitimate, but very difficult to answer. When I give my favorite Grand Rounds talk – Learning how to think like a clinician – I try to emphasize the importance of accurate diagnosis. Every day on rounds I am skeptical about diagnoses. I treat...
Source: DB's Medical Rants - August 4, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Antibiotic duration – a Goldilocks problem
Antibiotics save lives, but antibiotics can have negative effects. When patients have bacterial infections, we want to treat them to prevent complications of the bacterial infection, but not treat them for an excessive duration. So we have a Goldilocks problem – we want antibiotic duration to be just right – neither too short or too long.
Some clinical conditions have adequate research to define the Goldilocks duration. Community acquired pneumonia only requires 5 days of antibiotics, if the patient is clinically stable at 3 days. We know that 5 days is sufficient, so if we give antibiotics for 7 or 10 ...
Source: DB's Medical Rants - July 30, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
FeverPAIN vs the Centor Score
On twitter this week, several British tweeters discussed whether they should use the FeverPAIN score or the Centor score. Obviously I have a bias here, but I will try to discuss this issue dispassionately.
So I downloaded the PRISM study, where the authors proposed FeverPAIN. The goal of FeverPAIN is to increase the patient cohort not needing testing or antibiotics. As I studied FeverPAIN I found one important advance, but another point of naïveté.
To frame the discussion, the FeverPAIN study took all patients >3 years with sore throats. They used positive testing for group A, C or G beta hemolytic streptococc...
Source: DB's Medical Rants - July 25, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Guidelines – a major problem
Guidelines are wonderful; guidelines are dangerous. Over the past decade I have thought often about the benefits and the problems.
The first concept that attracted my attention was reading about conflicting guidelines. Given the same data, different guideline committees would have significantly different recommendations. At the least this problem raises questions about guideline validity. It makes clear that committee perspective could influence recommendations. Guideline recommendations sometimes are clear and demonstrably evidence based, but too often recommendations reflect the committee’s view of the pr...
Source: DB's Medical Rants - July 24, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
My OTF brag
First some context – I am a 68-year-old man who started doing OTF Labor Day weekend 2015 (thanks to my daughter). I had lost 35-40 pounds 2 years previously, and had kept them off. I was running regularly prior to OTF.
OTF attracted me because I saw that the workouts would complement my running and improve it. I knew that I needed some strength work and the treadmill variety that OTF provided.
OTF gives us the opportunity to test ourselves twice a year. During Peak Performance Week I focus on 4 activities.
The proof is in the Peak Performance Week times:
Event
June 16
Jan 17
July 17
500 meter row
1.4 min
1.34 ...
Source: DB's Medical Rants - July 21, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
15 years of blogging – exercise and weight loss
If anyone out there has followed this blog for the full 15 years, they will know that I have written about exercise and weight loss often. One stimulus involved my own journey to finally have extremely successful weight loss (starting Memorial Day weekend 2013) of 35-40 pounds. The weight loss took a year and I can safely brag that my weight this morning was at the level when I declared victory!
My writings, readings and personal experience have taught me much. Weight loss requires persistence, a great game plan, and perhaps some good genetic fortune. Weight loss maintenance requires the same things.
What follows i...
Source: DB's Medical Rants - July 19, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
15 ys of blogging – unintended consequences
When I started blogging in 2002, I did not understand where blogging would go. I took a rather vanilla name – medical rants – due purely to naivety. Perhaps if I could have seen the future I would have used the phrase unintended consequences in the blog’s title.
Medical care in 2017 suffers often from the unintended consequences that government has induced. I have written about this problem many times over the past 15 years. This problem is not just a US problem, but seemingly a problem throughout the world.
Our jobs have become unnecessarily complex. When Congress passes laws and when CMS devel...
Source: DB's Medical Rants - July 18, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Fitness goals and @otheoryfitness
As evidence expands that exercise and fitness has many positive effects, an increasing number of adults should consider improving their fitness. Several sources have convinced me that goal setting will help.
When I spent a year losing weight (approximately 40#), I had small achievable goals. I used a principle that Orange Theory Fitness put into words – “There is no after! All I am is before. There is no before and after, after implies that I am done. I AM NOT…THIS IS ME….BEFORE I GET EVEN BETTER.” As I was losing weight, I did not consider a final goal, because I needed small successes...
Source: DB's Medical Rants - July 6, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Medical dark humor
For medical students and residents, dark humor represents a major defense mechanism. I often tell the new students and residents – you cannot make up these stories. The stories are actually sad. The patients often have serious disease and complications.
But we do laugh and retell the stories. I will not give examples here, because without context they actually are not that funny.
I also tell the students and interns that the stories do not travel well outside the medical peer groups.
Over the past 44 years since I started my clinical rotations, I quickly learned that the stories belong within our peer group...
Source: DB's Medical Rants - July 2, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Diuretic use with a h/t to @kidney_boy
Residents and students at our institutions know that I am obsessed with diuretic use. Early in my career I met Dr. Craig Brater who produced much important knowledge of diuretic use. Too many physicians use diuretics without careful thought. I often discuss diuretic physiology and pharmacokinetics.
So listening to @kidney_boy talk with The Curbsiders this week was an absolute treat, #31: Diuretics, leg cramps, and resistant hypertension with The Salt Whisperer
Dr. Joel Topf (aka kidney boy), provides a great overview of diuretics. The talk focuses on several very important issues.
Diuretic choices for hypertension...
Source: DB's Medical Rants - June 28, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Larry Weed and SOAP notes
1973, as we prepare to start our clinical rotations, the chief medical residents taught us the new concept of SOAP notes. Larry Weed developed the concepts of the problem oriented medical record and notes that included subjective, objective, assessment and plans for each problem. We wrote our notes each day using his system.
I have wondered in many conversations what he would think of the unreadable computer printout notes of 2017. We wrote notes on each problem with a careful assessment and plan. We had no concern for doing a complete review of systems and physical exam each day, rather we focused on the patient&...
Source: DB's Medical Rants - June 25, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Asking learners questions #meded
I am currently reading Peak Performance a book about the processes that lead to our best performance. While the book has a general focus on athletics, it discusses principles and studies from many fields. This quote struck me as very important for medical education.
The most effective tutoring systems, on the other hand, all shared one thing: They delayed instruction until students reached the point of failure. Growth comes at the point of resistance. Skills come from struggle.
While many have argued against pimping, asking questions help our learners grow. The problem here is distinguishing pimping from safe questio...
Source: DB's Medical Rants - June 13, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Obtaining the HPI – a #meded opportunity
Recently our team was on call, and we had two early admissions. Fortunately for the team, we had a small census going into call and our patients were relatively stable. So instead for spending extra time rounding and teaching, we decided to see the two new patients as a group. We had each intern take the HPI and as they finished I supplemented their questions. Afterwards I gave them some tips on how to get a better history – immediate feedback.
Then after lunch we had one more admission. A student presented the story, and then I took the intern and 2 students to see the patient. This time I took the HPI a...
Source: DB's Medical Rants - June 8, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
