Developing expertise
This article has many important insights. One that I want to emphasize is the value of repetition in recognizing chunks. We have several situations in internal medicine that experts recognize and learners often do not. These concepts seem basic, yet too often we see a lack of understanding.
How do you interpret the vital signs? Seems simple and straightforward, yet learners often do not recognize the patterns. The CBC, the basic metabolic panel, the liver tests, EKGs, Chest X-rays – all of these seem routine and simple, yet experts view these tests in chunks and recognize patterns much more accurately.
As e...
Source: DB's Medical Rants - November 13, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Diagnostic errors
The BBC series Sherlock is brilliant. In episode 2 (called the Blind Banker) Sherlock enters a crime scene, and hears a rookie detective make pronouncements about a crime. He quietly asks a few questions about inconsistencies, but the rookie detective is undeterred. In true Sherlock fashion, he states (in a condescending tone) – “You have a solution that you like, but you are choosing to ignore anything that you see that doesn’t comply with it.”
Diagnostic errors occur in medicine and in other aspects of life. As I read the post-mortems on the election coverage, this quote comes to my mind. W...
Source: DB's Medical Rants - November 11, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Lessons for organized medicine from the election
Yesterday, KevinMD reprinted a Medrants post – Will someone actually let actually help patients? This post has had wide reposting on twitter and facebook.
As we read and listen to “experts” dissect the Trump victory, one theme seems to emerge – the lack of respect for the working class. While many remain mystified with Trump’s appeal, many opine that he convinced many that he heard them and understood them. An interesting op-ed in the WSJ – How Donald Trump Filled the Dignity Deficit -contains this paragraph:
Too many Americans have lost pride in themselves. We sense dignity by cr...
Source: DB's Medical Rants - November 10, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Sepsis bundles – why sensitivity and specificity matter
Graham Walker(@grahamwalker) tweeted this in response to yesterday’s blog post:
Agree w @medrants on Abx usage. Sepsis guidelines mandating Abx for anything that COULD be sepsis is the problem
I responded that his example is brilliant. Let’s dissect the problem.
Sepsis is a severe problem that responds better to early aggressive treatment.
Those invested in diagnosing sepsis desire bundles that have a high sensitivity. In case you forgot the definition of sensitivity, it is the true positive rate. Sensitivity here represents the percentage of sepsis patients that you treat promptly. Sounds good –...
Source: DB's Medical Rants - November 3, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Antibiotics – principles for best use
As physicians we worry about antibiotic resistance. Slowly, we understand that we can help slow down the development of more resistance through excellent antibiotic stewardship. Even Time Magazine has highlighted this problem.
In 2 weeks I will be a discussant in a PCORI sponsored workshop for this topic:
Smarter, More Appropriate Use of Antibiotics
Moderator:
Kara Walker, MD, MPH
Speakers:
Carey Bickford, Jeffrey Gerber, MD, PhD, Kathy Goggin, PhD, Dan Merenstein, MD
Discussant:
Robert Centor, MD, MACP
How can we use antibiotics more intelligently? I hope some of you will watch and listen to the discussion.
Antibiot...
Source: DB's Medical Rants - November 2, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Did you get your money ’ s worth today?
It started as a joke, but it has become a mantra. I discuss this phrase on the Curbsider’s podcast.
Our medical students pay (in my opinion) an obscene tuition. They are buying a medical education. Therefore we should remember that they are customers who have paid for our service.
As a clinician educator, I try to remember every day that I owe the learners my best effort. I have a wonderful career caring for patients and teaching those learners. The learners make my patient care responsibilities much simpler. But my job involves helping all the learners grow each day.
Learning internal medicine requires p...
Source: DB's Medical Rants - October 27, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Discussing internal medicine education on a podcast – The Curbsiders
That was a lot of fun. The Curbsiders invited me to answer questions on a podcast. Before we knew it, it turned into 2 podcasts. They released the first one today, in which I answer questions about my philosophy of ward attending rounds, feedback, bedside teaching and writing.
Next week they will publish our discussion of adult pharyngitis.
I have become a big fan of podcasts. Good podcasts tell stories and expand ideas to provide granularity. I have listened to many of the Curbsiders podcasts (available on their website and iTunes). They have a great concept and obviously have much fun doing the interviews. ...
Source: DB's Medical Rants - October 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
More thoughts on primary care and all that other care
Spend time talking with non-medical friends and acquaintances. Ask them about their medical experiences. Imagine what they want, or ask them what they want.
People want to feel that their physician has spent adequate time talking, examining and explaining. They want to look into the physician’s eyes. They want the best possible care, but caring matters.
Our “system” discourages such care implicitly. Physicians do not get paid to spend time with patients. Too often part of our payment includes performance measures. Too often we must enter data into computer systems designed to analyze data ra...
Source: DB's Medical Rants - October 17, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Solving the primary care crisis
We do have a primary care crisis. We believe that primary care delivers better care for less money. But primary care is under siege.
Why The Government Tried To Fix Primary Care And Failed
Many physicians do not believe in government solutions. As I understand the government solutions, they have great complexity.
One cannot “fix” primary care unless one really understands those features that make primary care advantageous. The key is time. Our current payment system discourages spending adequate time with patients.
While we cannot prove it, many believe that primary care physicians order tests and or...
Source: DB's Medical Rants - October 17, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM attendings – Chapter 18 – learning is more difficult than teaching
As a newly minted journal faculty member rounding on the wards, I had great internal pride in my teaching ability. Like many residents and junior faculty I assumed that my teaching would result in the learners growing dramatically (especially since I had delivered the messages so brilliantly {please read that phrase with true sarcasm}).
During my growth as an educator I learned that teaching can help, but not as dramatically as I would have liked.
Try this yourself. Teach something to your learning group. Wait a week or two and then quiz them. At first you will be despondent, but then take time to reflect. How...
Source: DB's Medical Rants - October 13, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The statin controversy
A friend asked me recently about statins. He takes a statin for primary prevention, but is concerned that he has muscle pain and weakness as a side effect. So he posed the question: “How important is the statin?”
The Washington Post had this recent article – Who should take statins? A vicious debate over cholesterol drugs.
But while nearly all experts agree that statins are beneficial for people at a substantial risk for heart disease, some medical researchers argue that statins do little or no good — and possible harm — for people at lower risk of heart disease. The conflict has burst into publi...
Source: DB's Medical Rants - October 9, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
What is next for the Affordable Care Act?
This well consider NY Times article is a “must read” – Ailing Obama Health Care Act May Have to Change to Survive.
Some have claimed great success for the ACA, because 20 million people now have insurance. These proponents emphasize the increased in “insured” and minimize the importance of the continued problems in the individual insurance markets.
Opponents of the ACA emphasize the problems, and ignore the benefits of 20 million more insured citizens.
The truth almost always resides between our polarized democracy. The act has helped some people (especially those with pre-existing cond...
Source: DB's Medical Rants - October 3, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Why we should change basic science teaching in medical school
Last night I watched a brilliant TED talk – Sal Khan: Let’s teach for mastery — not test scores – Ted Talk 2016
He makes the point that learners need to master the basics prior to attacking the next steps. As we consider this in medicine, how do we really learn pathophysiology if we do not understand the physiology.
Here is the challenge. Most basic science teachers suffer the Curse of Knowledge.
We need a commission of clinicians and clinical educators to identify the basics. Few students and residents understand the basics, but they do remember various arcane knowledge.
We should change how our lea...
Source: DB's Medical Rants - September 27, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Beware how the affect heuristic filters your view of data
The Spock in us would like to see data as hard, fixed, and totally interpretable. The Dr. McCoy in us understands that data do not have those properties. Nietzsche once wrote, “There are no facts, only interpretations”
In fact we always interpret “facts” in light of our biases. Our filters come from our preconceived opinions. If we like something, we give great value to “data” that support that belief, while we de-emphasize the negative findings. Vice versa works also.
When you watch the debate, if you like Hiliary Clinton you will cheer her pronouncements and believe them true...
Source: DB's Medical Rants - September 26, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Why I oppose home strep testing
Yesterday I read this tweet:
home strep test likely to reduce inconvenience, cost, strep complications, unneeded antibiotic and antibiotic resistance #medx
I disagree, but the reasons are fairly complex.
In order to understand this problem, we have to define the possible test, its use, the likely misuse and both the intended and unintended consequences of such a test.
What makes a good home test? Users should have no difficulty collecting the test sample. The test performance must be straightforward and simple. The test should answer a question that has a dichotomous implication.
Clearly, even health care profession...
Source: DB's Medical Rants - September 20, 2016 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
