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 inconsi...
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 20: Hyp...
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 we can m...
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