#PeakPerformanceWeek @OTheoryFitness
Today we finished Day 5 of Peak Performance Week. For those who have not yet tried OTF (Orange Theory Fitness), I will try to explain the brilliance of this week.
We all work out for personal reasons. Some start to assist with weight loss or weight maintenance (exercise is not enough, but it does help many); some want to improve their overall fitness; some see fitness as an important lifestyle for good health. I will admit to having all three above motivations.
Regardless, as you become committed to a workout routine, your would like some objective data that your fitness is improving. For the weight loss bunch, th...
Source: DB's Medical Rants - January 13, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Measurement for the sake of measurement makes no sense
Often over the past decade we have decried the rush to measurement. For those who believe that we can measure quality easily.
Enthusiasts have advocated for P4P without any data supporting this intrusion. Now the Annals of Internal Medicine has published a review that features this conclusion:
Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.
Will this end the P4P madness? Any practicing physician can explain the negatives of P4P programs – data col...
Source: DB's Medical Rants - January 12, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Do statins negatively impact exercise?
Statins decrease cardiovascular events. Exercise improves both the quantity and quality of life. But some patients experience difficulty exercising while on statins.
Here are a couple of articles: Men Who Take Statins May Exercise Less
What You Don’t Know About Statins and Exercise Can Hurt You
We rarely hear about this conundrum from cardiologists or cholesterol experts, but we do hear from our friends who take statins. While I greatly favor statins for secondary prevention, this conundrum defines a major problem in primary prevention. When the only reason to take a statin is your age (check the latest calculato...
Source: DB's Medical Rants - January 8, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Direct primary care – the answer or the problem?
This article about direct primary care induces conflicting analyses – Here is the PCP crisis solution and it’s simple
I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. Primary care physicians suffer high levels of burnout because the financial model requires them to see patients to quickly to do their job properly. These quick visits likely induce physicians to order more tests and consultations than they would if they could spend more time on history and physical examination.
Direct primary care a...
Source: DB's Medical Rants - January 8, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things that bug me 2 – lack of understanding eGFR
Once upon a time, we had to estimate GFR from the creatinine using an app or even a calculator. Now almost all labs provide estimated GFR, but this is both a positive and a negative.
I rarely find a resident (or attending physician) who understands the principles behind eGFR, and thus too often they interpret the number incorrectly and use it wrong. Here is my quick guide for understanding eGFR.
Back in the day, before the turn of the century, we measured 24 hour urines. We would measure the volume over 1440 minutes and measure the urine creatinine level. Given these numbers and the serum creatinine level, we would...
Source: DB's Medical Rants - December 30, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Recent thoughts concerning #OTheoryFitness
Over the past 16 months, I slowly became an Orange Theory Fitness (OTF) addict. My daughter convinced me to try a workout Labor Day weekend 2015. I began doing a few sessions over the following 3 or 4 months. At the beginning of this year, I went “all out”.
Currently on the wards, and my resident does OTF. I went to a small party the other evening and began talking about OTF with several other addicts (of course they are in their 20s and 30s). Like them, and many others OTF becomes an obsession. My running has improved, and my overall strength has advanced (same weight but decreased waist circumferenc...
Source: DB's Medical Rants - December 29, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Additional thoughts on diuretics – a followup to the furosemide rant
Yesterday’s screed about loop diuretics initiated more twitter activity than any blog post this year. Who knew?
Several comments bear documenting.
Important information on comparative absorption and duration of diuretics – A wonderful long range colleague (you should follow @kidney_boy on twitter) posted this infographic concerning this question on his blog. This is a most important link.
@Ajauseon tweeted this: “aspired to teach ‘evidence-based’ diuresis on CCU this month only to find there isn’t any” This tweet reminds me that EBM does not work for all questions. This qu...
Source: DB's Medical Rants - December 27, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Why do we still use furosemide as our first line loop diuretic?
We currently have 3 loop diuretic options – furosemide (Lasix), bumetanide (Bumex) and torsamide (Demadex). They are all currently generic and available for 50 cents or less per pill.
In the 70s, during my residency I believe furosemide was already generic. The remaining two loop diuretics became available after my residency and thus had higher prices for several years.
Here is the problem. Furosemide is inconsistently absorbed across people and averages only 50% but for some people absorption is even less. Bumetanide and torsamide get absorbed consistently and close to 95%.
Several times this month we had pa...
Source: DB's Medical Rants - December 26, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things that Bug me 1 – improper use of diuretics
This month on our VA ward team we have had 3 admissions that involved complications of over diuresis for systolic dysfunction. We also see patients who do not have adequate diuresis.
Diuretics greatly help symptoms in patients with systolic dysfunction and volume overload. But diuretics are primarily symptom relief medications.
I often ask students and residents to write this sentence, memorize it, and use it:
The purpose of diuretic therapy in systolic heart failure is render the patient not wet, but not to make the patient dry.
The idea here is that we should only give enough diuretic therapy to relieve symptoms. ...
Source: DB's Medical Rants - December 22, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
What should we do with work hours?
The Atlantic has this article – No Doctor Should Work 30 Straight Hours Without Sleep
After retweeting this article with this text:
Very interesting article that provides much outrage but no data. Many trainees prefer the longer shifts.
Here is a tweet response – I hated 16’s. Much prefer 24’s. But l wouldn’t continue a surgical residency w/o the weekly hr cap.
I work in a program where interns work 14-16 at most, but residents on some services do 24s. On some services, they have built a schedule so that most residents get sleep most of the nights. On others they get no sleep.
My current...
Source: DB's Medical Rants - December 19, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Focus on the HPI – #meded
During my 37 years of inpatient internal medicine teaching, my style has evolved. Periodically I try something and the feedback that I receive changes my standard style in a significant way. Students and residents stimulated my recent focus on teaching the HPI.
As educators we should first understand our goals. Obviously, patient care trumps everything, but once that is accomplished we all want to help our learners grow. Experienced and inexperienced educators quickly notice the student or intern who delivers smooth informative presentations. A recent JAMA viewpoint addressed this issue – The Oral Case Pr...
Source: DB's Medical Rants - December 16, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Millennials are really not different
We baby boomers have much in common with our predecessors. Every generation seems to think that the newest generation does not measure up to their great standard. My friend and colleague Goop Dhaliwal wrote a wonderful paper in JAMA – The Greatest Generation
It is possible that in the days of giants, the narrator did unsupervised burr holes as an intern and had mastered the physical examination by the second year of residency. Beware, though, that each time we replay those autobiographical memories about our training, we are prone to make the situation more harrowing or ourselves more dedicated or skillful than t...
Source: DB's Medical Rants - December 11, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Diagnosis – the adjectives are just as important as the nouns
This article from the Clinical Journal of the American Society of Nephrology speaks loudly to this problem – The CKD Classification System in the Precision Medicine Era
Chronic diseases of the kidney range from rare inherited disorders, such as Fabry disease, to more common acquired entities, such as diabetic kidney disease. Despite the myriad clinical phenotypes and histopathologic subtypes, even within, for example, diabetic kidney disease, this diverse collective is viewed similarly when estimates of glomerular filtration align. Contrast this approach with that of multiple myeloma, a diagnosis that prompts routine...
Source: DB's Medical Rants - December 6, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
We should encourage exercise – but how can we be successful
The reasons for encouraging exercise are many. Readers know that I am an exercise addict. As a child, adolescent and young adult, basketball was my main addiction. I remember deciding to stop playing at the age of 44. As we age, we get hurt more and take longer to recover. I hated giving up my favorite sport. The joy of a great pass, or a clutch shot remains in my memory.
Over the next 20 years, I exercised intermittently. I would go through periods of steady exercise, and then revert to extra couch time. Over these years I gained more weight than was healthy or desirable.
I have reported on my return to re...
Source: DB's Medical Rants - November 29, 2016 Category: Internal Medicine Authors: rcentor Tags: Fitness & weight Source Type: blogs
Thankful to have become an internist
November 1973 I had an epiphany. My first week on my internal medicine clerkship, I realized that I had found my specialty – internal medicine.
Prior to medical school I had worked with emotionally disturbed children in an inpatient hospital. I really enjoyed the experience, and learned a great deal. During my first two miserable years in medical school (I disliked how they taught the basic sciences and even more how they tested), I had considered pediatrics, psychiatry, and a great blend in adolescent medicine. Parts of medicine fascinated me, but getting out of the classroom was freedom.
I started my third ...
Source: DB's Medical Rants - November 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
