Help your future colleagues
As a ward attending physicians, we have a great opportunity and responsibility. We are helping patients and helping our future colleagues grow into the physicians that patients need. Ward rounds are never about making the attending physician’s ego grow. They are always about patients and learners. We must embrace servant leadership as a way to lead rounds. I have written about this concept for many years. These old posts are (IMO) worth rereading. On treating medical students with respect And this one Tips for IM ward attendings – Chapter One – servant leadership The problem is pers...
Source: DB's Medical Rants - September 7, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The danger of assuming
Recently I have spent much time listening to linguistic podcasts. They have triggered many thoughts about how we take histories from patients. Linguistics represents a very complex science of language. One concept that has intrigued me involves the meaning of words. When we hear words or read words, we automatically assign a meaning to those words. Too often, especially when we are students and residents, we make assumptions about meaning. However, with experience we learn that words mean different things to different persons. Experience teaches us that certain words have different meanings amongst patients. Thus, w...
Source: DB's Medical Rants - August 21, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

On Casuistry, Guidelines and Performance Measures
Malcolm Gladwell’s wonderful podcast – Revisionist History – has just focused 3 episodes on the Jesuits and their use of casuistry. I was not familiar with the term, so here is one definition – Casuistry is – a resolving of specific cases of conscience, duty, or conduct through interpretation of ethical principles or religious doctrine. As I listened to these episodes, of course I pondered what this means for medicine. Perhaps I have massaged the idea beyond recognition, but the podcasts did stimulate these thoughts. The intent of guidelines (at least I think) is to provide a general...
Source: DB's Medical Rants - August 3, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Thoughts after a year of podcasting
Twelve months of podcasts – 2 per month – are now available at Annals on Call. During those 12 months, I have learned a lot from my guests and learned a great deal about podcasting and interviewing. Many have asked me to tell them the story of the podcast – how did it come bout? how long does it take to podcast? how do I pick guests and topic? So here is my story. A couple of years ago Dr. Christine Laine, the excellent editor of the Annals of Internal Medicine, asked me if I would do something “social media” for the Annals. We talked about blogs and podcasts. For the next year, we decid...
Source: DB's Medical Rants - July 25, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Podcasts for UME, GME, CME – rationale
Readers know that I have become rather obsessed with medical podcasts over the past 2 years. I host Annals on Call, and have appeared on The Curbsiders and the Clinical Problem Solvers. I admire Bedside Rounds and CoreIM in particular. As I talk with students and residents, the enthusiasm for medical podcasts is growing and exciting. I personally get excited that our learners find podcasts a wonderful way to expand their medical knowledge. My peers listen to many podcasts. We often recommend podcasts and especially individual episodes to each other and our learners. Just yesterday we had a patient with true syncope. I ...
Source: DB's Medical Rants - June 30, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Setting expectations for new clinical learners
Monday morning we have new interns and new 3rd year students. During rounds I will set expectations for their first clinical rotation at these levels. (I also have a new 3rd year resident, but he has had all 2nd year to learn how to be a resident). What should I expect; what should they expect? In setting expectations we should try to remember our own experiences and feelings. They will be very excited and a bit scared. The interns are really doctors now, and feel that responsibility. Many have the impostor syndrome. The 3rd year students really are “newbies”, as the 3rd year of medical school has little in ...
Source: DB's Medical Rants - June 23, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Understanding diagnostic excellence
When we think about clinical reasoning, most talks focus on diagnostic errors and the reasons for those errors. The legacy of Kahneman and Tversky focuses on errors and the many named mistakes we make. We focus on avoiding errors, but their work and too often our teaching does not focus on the road to diagnostic excellence. Gary Klein, the pioneer of naturalistic decision making, has focused more on the road to excellence. These are not two sides of a coin, but rather separate important concepts for us to understand. The road to excellence is likely more challenging than the road to avoiding errors. The road to excellen...
Source: DB's Medical Rants - June 20, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Things that bug me – telling me normal (CBC, BMP)
Dr. Rabih Geha’s excellent post on Closler – Every Piece of Data Matters – has stimulated much thought. He makes one important point that I would like to expand. My mind finds it much harder to attach diagnostic significance to pertinent negatives. Even if their impact on a diagnostic hypothesis is equal, I find that a positive test result sways my reasoning more so than an equally impactful negative test. My students and residents know that I want to hear the numbers. Sometimes normal is not normal. Sometimes seemingly normal gives clues. The problem comes from our laboratory definition of no...
Source: DB's Medical Rants - June 10, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Mystery novels, cold cases and the diagnostic process
Currently listening to David Baldacci – Redemption. The mystery novel, like many others, demonstrates important diagnostic principles. The story is one of missed diagnosis – in the mystery the detective is asked to reopen a case. Once he reconsiders his first murder case (13 years later), he recognizes mistakes that he made. He carefully reanalyzes several pieces of evidence considering how they fit the original assumptions. Once he decides that he needs to reinvestigate, he returns to the scenes of the crime. He re-examines the evidence; he once again interviews potential suspects; he focuses on inconsis...
Source: DB's Medical Rants - May 6, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Podcasts for medical students on internal medicine
Today, we received two 3rd year medical students starting their IM rotation. I told them I would give them a list of podcasts that should help them get oriented to internal medicine. This is my podcast v1.0 list: From the Curbsiders: 142 Cirrhosis TIPS for Acute Complications 104: Renal tubular acidosis with Kidney Boy, Joel Topf MD 92: Pulmonary Embolism for the Internist 86: COPD: Diagnosis, treatment, PFTs, and nihilism 76: Pneumonia Pearls with Dr Robert Centor 61: Vasculitis and Giant-Cell Arteritis: ‘Rheum’ for improvement 52: Anemia: Tips, and tools for diagnosis and treatment ...
Source: DB's Medical Rants - April 29, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Lessons learned from the National Champions
All physicians have failures. The best physicians learn from those failures. They become better physicians and work on continuous improvement. Everyone who knows me well knows that I have had a 52 year obsession with UVa basketball. While I love all the sports teams, basketball is my true love. Better wordsmiths than me would have a difficult time explaining my joy in Monday night’s championship game. You can imagine my dark place after last year’s loss in the first round. So what does this have to do with medicine. Maybe nothing, but we can learn important lessons from literature, music and sports. In th...
Source: DB's Medical Rants - April 10, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Confusion after gastric bypass with Roux-en-Y
At at recent case conference, we discussed a woman who had had a gastric bypass 20 years previously, and now had confusion. To remind you of the details of a gastric bypass: First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine furt...
Source: DB's Medical Rants - April 1, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The role of podcasts in medical education
Obviously I am very biased, hosting a podcast now for 8 months, and being a guest on two other popular podcasts – The Curbsiders and The Clinical Problem Solvers. Given my obvious COI, here are my thoughts on the contribution that podcasts are making for students, residents and practicing internists. Two or three years ago some students asked me if there were any good podcasts to listen to while on their medicine clerkship. Soon thereafter, two things happened: The Curbsiders started their podcast and the Annals of Internal Medicine asked me to develop a podcast. I had a growing love of podcasts as an accompanimen...
Source: DB's Medical Rants - March 28, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The problem of admission diagnoses – a guest post
I received this response to a recent post. It is so good that I wanted to share it – so with Dr. Thomas Nielson’s permission I have. He makes the important point that the rush to LABEL the patient with the diagnosis has major unintended negative consequences. He says it so well that I encourage your reading and comments. Thank you for this post. This is a problem that occurs from time to time, and I believe that the current system in place for admissions is a large part of the problem. We are asked to diagnose people in the emergency department because we need an “admission diagnosis” so that ...
Source: DB's Medical Rants - March 25, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The danger of ignoring your instincts
Recently we had a patient admitted for a diagnosis that did not really fit his problem representation. The diagnosis was a convenient one, and easily treated. He initially responded to treatment and we discharged him. The diagnosis assumption nagged at me, but I did not push forward with a test that my mind wanted. A week later he returned (the dreaded readmission), with the same symptoms. The admitting resident expanded the treatment for the same diagnosis. The next morning on seeing the patient we were even more uncomfortable than on the first admission. As often happens, this is a story of community acquired p...
Source: DB's Medical Rants - March 16, 2019 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

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 acce...
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 article adds to the emerging story of the dangers of incompletely treated Fusobacterium necrophorum pharyngitis. This article has a wonderful discussion section (of course they cite our work favorably). The gist of the article is included in the abstract : One hundred fifty-six of the 990 patients in our study developed recurrence of their abscess (16%). The age ranges most susceptible to recurrence included adolescent (22.9%) and young adult groups (17.1%) … The presence of FN was significantly more prevalent in the recurrent group (P?
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 c...
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 p...
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...
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 s...
Source: DB's Medical Rants - October 26, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Unintended consequences of health policies – heeding HL Mencken and Gary Klein
Unintended consequences of health policies can have dramatic negative impacts.  HL Mencken wrote 98 years ago,  “Explanations exist; they have existed for all time; there is always a well-known solution to every human problem—neat, plausible, and wrong.” (https://quoteinvestigator.com/2016/07/17/solution/)  When policy wonks and legislators and rule makers seek to solve problems in medicine they seemingly forget this admonition. Here are 3 examples of poorly considered solutions: Electronic health records – in the abstract this seems like an obvious idea.  But the problem they a...
Source: DB's Medical Rants - October 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The value of fitness
Long time readers know that I often write about exercise and fitness.  Over the past 3 years I have written often about Orange Theory Fitness.  OTF focuses on high intensity interval training (cardio) complemented by strength work.  Working out regularly makes me feel better in many ways, and I would do it for a variety of reason, but this new article adds even more fuel to my OTF fire.  Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults Undergoing Exercise Treadmill Testing.   The article is free.  CNN has a great article explaining the study – ...
Source: DB's Medical Rants - October 21, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Philosophical musings on tests in medical school and beyond
Yesterday I read the latest “On Being A Doctor” in the Annals of Internal Medicine.  The story – Murky Water – tells the story of a classmate who committed suicide after failing step 1 by 1 question.  Over the last 12 hours I have pondered this story as well as an article in the same issue titled The MCAT’s Restrictive Effect on the Minority Physician Pipeline: A Legal Perspective. What do standardized tests tell us?  In college, as a psychology major I took a course in Psychometrics.  I understand the principles behind designing tests that produce bell shaped curves. ...
Source: DB's Medical Rants - September 30, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

The suffering man resolved
This article  Polymyalgia rheumatica vs late-onset rheumatoid arthritis   adds some confusion to my previous conclusions. This abstract continues my confusion – Presenting features of polymyalgia rheumatica (PMR) and rheumatoid arthritis with PMR-like onset: a prospective study So I am not sure about the final diagnosis because he definitely had characteristics of both.  The good news is that both respond to low dose prednisone.   (Source: DB's Medical Rants)
Source: DB's Medical Rants - September 27, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

A suffering man
Around 20 years ago, while I was still doing outpatient medicine, a 65-year-old construction worker came as a new patient with diffuse pain.  His story gave many clues. 3 months prior, he was working on construction in the Mobile area.  One task of his involved carrying concrete blocks.  One day he could no longer grip the blocks because of hand pain.  This pain did not resolve with NSAIDs.  He had to stop working. Over the next months he developed more pain including his shoulders and hips.  As he walked into the examine room, he was almost shuffling and clearly was uncomfortable.  He ha...
Source: DB's Medical Rants - September 26, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Some thoughts on clinical judgement
Thus far I have recorded 8 podcasts for Annals on Call, 4 of which have already been published.  The term and concept of clinical judgement enters the conversations repeatedly.  Each podcast has had a different guest, yet in most of these conversations I have heard clinical judgement invoked.  What is clinical judgement?  Do we just use the term when we want to stray from protocol or algorithm?  I found this definition which gets us part way to an understanding. For purposes of description, it can be considered the sum total of all the cognitive processes involved in clinical decision making. It in...
Source: DB's Medical Rants - September 20, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

@orangetheory – my 3 year anniversary
Early this morning I attended another great OTF class.  3 years ago my daughter took me to OTF.  My schedule that fall was incredibly busy, so it took a few months for me to go “all out” for OTF.  My addiction started slowly, but within 6 months I was gung ho.  And since then I have attended class around 4 or 5 times each week. To this day, I have not tired of OTF.  The workouts challenge me daily.  They work.  At age 69 I am in better physical shape that in my 40s. I joined as a runner – used running and diet to lose 40 pounds started May 2013 and finishing May 2014.&nb...
Source: DB's Medical Rants - September 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

My approach to acute pharyngitis 2018
First, we must define acute pharyngitis – no more than 3-5 days of symptoms. Second, we should understand that pre-adolescent pharyngitis has major differences form adolescent/you adult pharyngitis.( Mitchell, M. S., Sorrentino, A., & Centor, R. M. (2011). Adolescent pharyngitis: a review of bacterial causes. Clinical Pediatrics, 50(12), 1091–1095. http://doi.org/10.1177/0009922811409571 )  Here are the differences: Pre-adolescent pharyngitis really is group A strep vs viral Adolescent pharyngitis has a much broader differential – GAS, Group C/G strep, Fusobacterium necrophorum, infectious monon...
Source: DB's Medical Rants - September 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

db ’ s anion gap pearls
This article describes the precise formula.  We use albumin times 3 as a reasonable estimate. (Source: DB's Medical Rants)
Source: DB's Medical Rants - August 27, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs

Show respect for how hard your interns and residents work
As we age, we look back and convince ourselves that we were better and worked harder than the current generation.  Dr. Gurpreet Dhaliwal addressed this issue beautifully in an essay – The Great Generation Today’s trainees are every bit as professional, motivated to learn, and devoted to their patients as previous generations. Students and residents follow duty hours but then log on from home to monitor their patients, write orders, and stay in touch with their on-call colleagues.7 They come to the hospital on their mandated days off for family meetings. They connect with their patients despite unprece...
Source: DB's Medical Rants - August 24, 2018 Category: Internal Medicine Authors: rcentor Tags: Attending Rounds Source Type: blogs