ACP delivers a position paper on administrative burdens
This article is free to all, and a must read. Now we need action.
In the same issue, Dr. Chris Sinsky writes a wonderful editorial – Designing and Regulating Wisely: Removing Barriers to Joy in Practice.
Physicians may now spend more time documenting care and complying with administrative and regulatory requirements than caring for patients…
The high volumes of clerical work, along with poorly designed technology, and the resultant time pressures are among the major drivers of alarming levels of physician burnout…
The medical community has come to expect evidence-based medical practice. A similar expect...
Source: DB's Medical Rants - March 28, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Clinician educators – local respect and national anonymity
I spent this week as a visiting professor at the University of Nebraska Medical Center. My long time friend and colleague, Dr. Robert Wigton, has endowed this professorship. I gave a few talks, and met with many clinician-educators. The groups included internal medicine hospital specialists, outpatient specialists and med-peds faculty. I worked predominantly with junior faculty, discussing their careers and how to improve.
During these many conversations I spoke with several senior, highly respected clinical educators. These stars have influenced and taught Nebraska medical students for years. Talk to any gradu...
Source: DB's Medical Rants - March 25, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
My developing thoughts on adult pharyngitis
MDCalc invited me to write a blog post about pharyngitis (they had previously asked me to comment on the Centor score).
That post includes much of my current thinking – Sometimes it’s NOT just a sore throat – adolescents and young adults are different
The other important concept that I did not include in that post came up in a conversation I had yesterday at the University of Nebraska where I am this week as a visiting professor. A clinician educator asked me about “red flags” in sore throat patients. While I have written this previously, repetition helps all learners remember.
Adult sore throats ...
Source: DB's Medical Rants - March 23, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things that bug me – 5 – ordering orthostatic BP rather than doing it oneself
This happens too often in my opinion. A patient comes to the emergency department after a syncopal episode. The next day on rounds, the intern reports that h/she order orthostatic BP but it was not done.
Now, some medical pundits have suggested that the physical exam is no longer relevant. No serious internist really believes that.
The first step in evaluating syncope is checking for orthostatic hypotension. If the patient does have orthostatic hypotension, then the pulse response can certainly help.
In such patients, measuring the BP and pulse is usually the most important part of the physical exam. Then why do ...
Source: DB's Medical Rants - March 14, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things that bug me 4 – inadequate specification of symptoms or diagnoses
The patient had diarrhea last night.
The patient complains of chest pain.
The patient has diabetes (or CKD or heart failure).
What do these 3 sentences have in common? When I hear them or read them, I want to know more!
Perhaps explaining what I want to know will make the point clear.
Please describe the diarrhea – how many? watery or loose? incontinence? exactly when did it start? does it persists?
Where is the chest pain? What is the characteristic of the pain? Does it radiate? How long does it last? …
How long as the patient had diabetes, and which flavor of diabetes does h/she have? What m...
Source: DB's Medical Rants - March 7, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Old school medical education
As I have the opportunity to give my talk titled Learning How to Think like a Clinician, many older physicians want to talk afterwards. Usually they lament the current state of clinical skills – both history taking and physical examination. Now I suppose they may overestimate the skills that they currently have and were taught, but we often do talk about the skills that help internists do their job well.
Students and residents seem extremely interested in learning the skills of history taking and physical examination. But the old school crowd and the learners suggest that many younger clinician educators do no...
Source: DB's Medical Rants - March 3, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things that bug me 3 – vanc and pip/tazo
This study shows clearly that vanc & pip/tazo have a negative synergistic impact on the kidney. The most interesting point in the article (to me) is that vanc trough levels predict AKI in vanc/cefepime but NOT in vanc/pip-tazo.
So in 2017 I fear vanc/pip-tazo. Patients on this combination had a length of stay averaging 2 days longer!
The housestaff with whom I work know my fear, and work hard to avoid the combination. Perhaps they are actually being more thoughtful about antibiotic choices. That would be good for our patients. (Source: DB's Medical Rants)
Source: DB's Medical Rants - February 16, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Why you should read the Undoing Project
The Undoing Project, the new Michael Lewis book (Big Short, Blindside, Moneyball), tells the story of Kahneman and Tversky – 2 Israeli psychologists who challenged assumptions of rationality and decision making. I first heard Tversky at a Society of Medical Decision Making meeting. He presented their work and emphasized the concepts of heuristics and biases. Over the past 35 years, I read their papers, and when Kahneman’s book – Thinking Fast and Slow – appeared I read it carefully.
Lewis takes us to the beginning of their collaboration. He paints a picture of two very different men, from d...
Source: DB's Medical Rants - February 12, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
An insight on the challenge of changing behavior ( h/t @gretchinrubin )
Veteran readers know that I had a major behavior change in 2013 – becoming an exercise addict and improving my eating habits. I lost approximately 35-40 pounds, and have kept that weight off for almost 3 years now. The big question that my friends and acquaintances ask me is how did I do it. My stock answer really is too simple – exercise more and eat less. I had some idea of why I had success, but did not really understand why what worked so well for me might now work for others.
Last week I heard a wonderful interview with Gretchin Rubin (the podcast was Run to the Top). She talked about the four te...
Source: DB's Medical Rants - February 7, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Meet your exercise goals, not others ’
Over the past 2 days I listened to a wonderful podcast – Life at the Back of the Pack: The positive spirit of the Sub-30 Club; Ted Spiker on leading from the back.
Ted Spiker writes a wonderful blog – the Big Guy Blog. Several years ago, he had a goal of breaking 30 minutes for a 5k. He wrote about it, and invited readers to join him in a support group. Now the sub-30 club has over 4000 members. They have custom T-shirts, meet ups, and new traditions. They often have scheduled partying in the middle of the race.
The subbers (as they call themselves) have an overarching principle – support each m...
Source: DB's Medical Rants - February 1, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Advice for students and residents – always remember that the patient is a person
The title could (and should) provoke controversy and concern. Yesterday, I was giving feedback to my interns and resident after a 2 week VA rotation. We had an interesting 1/2 month. Several patients stand out, not because of their disease, but because we focused on them and how to help them.
A phrase I often use points out that we have two jobs, treat the disease and treat the person. Understanding the person with the disease often trumps understanding the disease. We have many patients for whom we have no more options to eradicate the disease. We always have options to help the person.
Patients can tell if yo...
Source: DB's Medical Rants - January 30, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Estimating maximum heart rate is difficult – attn @OTheoryFitness
Orange Theory Fitness encourages working to achieve zones that your maximum HR defines. When I started, I knew that the routine formula (220-age) for men did not work for me. I am 67, which predicts a maximum heart rate of 153, yet multiple times I have proved that my maximum is around 170. Given this discrepancy, I began wondering about the max HR.
Yesterday, on a message board, an Orange Theory regular wrote that he could not get to the orange zone (84%-91%) very often. Research has shown that the estimation formulas (the one cited above as well as others) both overestimates and underestimates in individuals.
Bac...
Source: DB's Medical Rants - January 28, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
On binge drinkers
Doing hospital medicine, we often have patients come in for complications of binge drinking – acute pancreatitis, GI bleeding, trauma, hypothermia, etc. Many such patients know they are alcoholics, and have spent considerable time not drinking. Over time (often I am a slow learner) I have realized that most such patients are drinking to become numb.
I should have known. How often do we watch a television show or movie and see a character go off on a bender because of some traumatic event? Just last night I was watching Lethal Weapon (the TV show). Riggs (the main character) starts drinking very heavily as t...
Source: DB's Medical Rants - January 26, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The joy of being a teaching and learning internist
Since December 1st, I have made attending rounds all but 10 days. As usual, this stretch has invigorated me.
As an internist (I am eschewing the phrase general internist because I believe that the adjective general is redundant), my teams care for a wide variety of patients. Some patients have given us diagnostic challenges, while others management challenges. Many patients need the right side of our brain, while others need the left side. The best internists have balanced brains!
As a teacher, I love inducing excitement in the learners. When we figure out the diagnosis, we feel like Sherlock Holmes.
As a learner...
Source: DB's Medical Rants - January 24, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Understanding why we have strong differences interpreting the same “ facts ”
In the past I have written about the affect heuristic.
The affect heuristic is a swift, involuntary response to a stimulus that speeds up the time it takes to process information. Researchers have found that if we have pleasant feelings about something, we see the benefits as high and the risks as low, and vice versa. As such, the affect heuristic behaves as a first and fast response mechanism in decision-making.
Now I have learned about two related concepts. These concepts both explain biases in reasoning – the myside bias and motivated reasoning. Learning more about these concepts should help us better under...
Source: DB's Medical Rants - January 15, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
