Advice for new 3rd year medical students and soon to be interns
Learning clinical medicine is difficult. It often seems overwhelming. I offer this advice, as I have for many years to students.
Assume that you will be confused and overwhelmed each time you start a rotation. Some rotations take longer before you feel comfortable. My specialty – Internal Medicine – is usually the most confusing when you start. If you feel like you are drinking from a fire hose, you are not alone. Amazingly, rotation after rotation, students start to feel comfortable in around week 3 or 4.
Maximize your learning from patients. I recommend keeping a notebook (either paper and pen o...
Source: DB's Medical Rants - June 5, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The goal of medical education #meded
I started medical school in 1971 (yes 46 years ago). Hated the first two years, but loved the 3rd and 4th years and loved my residency.
My first month as a ward attending in Internal Medicine was January 1980. I probably have averaged over 100 days of teaching attending for the past 37 years.
What do our learners need? They need (and almost always want) to become excellent physicians. They want us to help them grow as clinicians.
Internal medicine is a very intellectually challenging specialty. We cover multiple organ dysfunctions. We learn more each year about how to best diagnosis and treat patients.
Our lear...
Source: DB's Medical Rants - May 29, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The joy of teaching rounds
January 1980 I had my first experience as a teaching ward attending. I loved it. 37 years later, I love it.
I just spent most of 4 weeks traveling. This Monday I started a 5 day stint rounding. Each day I am excited. As we discuss patients; as we see patients; I get more excited. Our patients provide our students and residents so many opportunities to learn.
Excellent inpatient internal medicine does require attention to many details. Sometimes we need to carefully take the history. Sometimes the physical exam gives us great information. Other times we need to best interpret the laboratory tests.
Sometime...
Source: DB's Medical Rants - May 25, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
15 years of blogging – a retrospective
May 19th, 2002 I wrote my first blog post. Blogging had just become an interesting method for expressing opinions.
Early in my blogging career I compared blogging to standing on a soap box in Hyde Park. Bloggers had (and have) the freedom to express opinions. Readers have the opportunity to comment, ignore or just read.
I started blogging to “cure” writer’s block. Blogging allowed me to try out ideas. Some blog posts stimulated academic articles and research.
One particular post, from September 2002, has led to my recent research into Fusobacterium necrophorum pharyngitis:
Some sore throats are ...
Source: DB's Medical Rants - May 22, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Compression of disability should be everyones health goal
What are you doing to maintain vigor as long as feasible? Fries wrote a classic article in the NEJM – Aging, Natural Death and the Compression of Morbidity.
Fries argues that chronic disease is our foe – avoiding chronic disease allows us to wait longer until we develop morbidity. The ideal situation is excellent health until 90 then die in your sleep.
How do we do that? Unfortunately, some people develop chronic diseases that we do not know how to prevent. However, any physician will tell you that much chronic disease develops because of lifestyle choices. Here is my list of lifestyle choices that pr...
Source: DB's Medical Rants - May 18, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Repetition and the basics – #meded
Discussing a new patient recently, two important teaching points crystallized once again. The patient was relatively young without any past medical problems. He had dyspnea, first on exertion, and then at rest. On exam he was tachypneic with crackles, wheezes and rales throughout his lungs. After receiving nasal oxygen he “looked comfortable”.
His electrolyte panel:
135
90
8
103
4.8
30
0.6
So I asked why his bicarbonate was 30.
A fairly long discussion ensued. The major point of the discussion was that an elevated bicarbonate here might be a danger sign. I believed (as did a critical care ...
Source: DB's Medical Rants - May 14, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
AI + physicians
Some enthusiasts believe that computers the answer to diagnostic errors. As I have written before, the biggest problem with AI comes from data entry. Who collects the data and who picks which data to enter?
Mukherjee has an interesting article in the New Yorker about AI.
The most powerful element in these clinical encounters, I realized, was not knowing that or knowing how—not mastering the facts of the case, or perceiving the patterns they formed. It lay in yet a third realm of knowledge: knowing why.
AI does wonderful work when paired with a clinician who understands which data the computer needs.
Our most importan...
Source: DB's Medical Rants - April 30, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Journalistic malpractice – the diet soda study
Sitting in Israel writing this blog post, drinking a diet coke, and wondering what they were thinking.
You have read the headline, or heard it on TV or the radio – diet sodas cause dementia and strokes.
That was the headline, but any careful analysis of the study suggests that they did not PROVE anything.
Aaron Carroll – the Incidental Economist – has a great analysis – They did not prove that diet soda causes Alzheimer’s Disease. THEY DID NOT!
For a profane, but funny take – DIET COKE WON’T CAUSE STROKE, BUT READING SENSATIONALISTIC HEADLINES MIGHT
The problems in short:
Too many compari...
Source: DB's Medical Rants - April 26, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Interpreting and evaluating the Centor score
In response to a twitter request, this post will in detailed fashion discuss the score, how I recommend using it and how to evaluate it. I will go into more detail than I generally do, because the questions require that detail.
The original study, published in 1981 based on data collected in 1980, used logistic regression to evaluate predictors of positive group A beta hemolytic streptococcal cultures taken from adults (aged 16 and above) coming to an emergency department for a chief complaint of sore throat. We collected candidate symptoms and physical examination signs.
The idea was always to use the resulting scores...
Source: DB's Medical Rants - April 23, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
A personality trait that may help us minimize diagnostic errors
I found this article fascinating – The Surprising Personality Trait That Massively Improves Decision-Making, According to Science
The trait is called intellectual humility!
In everyday language, it means the willingness to accept that you might be wrong and to not get defensive when arguments or information that’s unfavorable to your position comes to light.
In medicine, we often have to assume a diagnosis when a patient enters the hospital. We often assume a diagnosis in outpatient settings. In both cases, we then should look for confirmatory evidence to either support our assumption or counter our assump...
Source: DB's Medical Rants - April 18, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Thanks for listening
When we walked into the room, you could sense the anger and frustration on the patient’s face, as well as two other relatives in the room. We knew that the patient had had lung cancer for several months and had failed radiation and chemotherapy. He had labored breathing and looked miserable.
I went to his bed and asked if I could sit down on his bed. I took his wrist and began checking his pulse. Then I asked him to tell his story.
The 50-something patient had many pack years of cigarettes. He understood his diagnosis and wanted to pursue further treatment options. His breathing had worsened, partly due t...
Source: DB's Medical Rants - April 16, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The best physicians are multidimensional
No, this is not a science fiction reference. Rather this represents, at least in my mind, the many skills necessary to become a superb clinician. I write this from the perspective of an internist, but I believe these skills are not specialty specific.
History taker – most patient encounters start with taking a thorough history. We have to learn how to ask questions and varying our words according to the patient’s background. We take a different history from a college graduate than we do from a rural farmer. History taking also requires understanding what each answer means and what follow-up questions...
Source: DB's Medical Rants - April 15, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Exercise in ones 60s – more on my #OTheoryFitness obsession
Regular readers know that I am currently an exercise addict. Once one becomes eligible for Medicare, thoughts turn to maintaining quality of life and health (if we are fortunate enough to have good health).
I play golf regularly, mostly with guys my age. The great majority of my friends have an exercise regimen with the following goals:
Maintain leg strength
Improve balance
Avoid falling
Some level of aerobic activity
Our fear is falling and breaking a hip (or worse hitting our heads). So this great group of guys are all taking different paths towards maintaining their best achievable fitness.
I have turned to Oran...
Source: DB's Medical Rants - April 6, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Metacognition about teaching
During my early years as a faculty member, instinct guided my teaching style. I really did not think carefully about teaching style or techniques.
Meeting Kelley Skeff and spending a month learning about teaching at Stanford changed that. He provided me a vocabulary and examples to allow me to develop metacognition. What do I mean when I type metacognition – awareness and understanding of one’s own thought processes.
If we want to help our new faculty, we should expose them to ideas about teaching. We should provide a vocabulary to use in evaluating others and themselves.
Reflect on your own teaching. ...
Source: DB's Medical Rants - April 3, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Mentoring for clinician educators
In visiting many institutions and talking with many young clinician educators, the lack of mentorship for these positions appears striking. No one would hire a researcher without adequate training, nor a subspecialist without the appropriate fellowship, yet we often hire physicians directly out of residency and give them the responsibility of being a ward attending physician. This repeated occurrence makes a statement about how many medical schools value medical education. They implicitly tell us that anyone can teach medical students and house officers.
Most departments and schools spend little effort or money to tr...
Source: DB's Medical Rants - April 1, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
