Unintended consequences of health policies – heeding HL Mencken and Gary Klein
Unintended consequences of health policies can have dramatic negative impacts. HL Mencken wrote 98 years ago, “Explanations exist; they have existed for all time; there is always a well-known solution to every human problem—neat, plausible, and wrong.” (https://quoteinvestigator.com/2016/07/17/solution/) When policy wonks and legislators and rule makers seek to solve problems in medicine they seemingly forget this admonition.
Here are 3 examples of poorly considered solutions:
Electronic health records – in the abstract this seems like an obvious idea. But the problem they address is very compl...
Source: DB's Medical Rants - October 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The value of fitness
This study differs from previous studies because they have data on fitness (the treadmill performance) rather than patient reports on exercise.
The study population included 122?007 patients (mean [SD] age, 53.4?[12.6] years; 72 173 [59.2%] male). Death occurred in 13?637 patients during 1.1 million person-years of observation. Risk-adjusted all-cause mortality was inversely proportional to cardiorespiratory fitness and was lowest in elite performers (elite vs low: adjusted hazard ratio [HR], 0.20; 95% CI, 0.16-0.24; P?<?.001; elite vs high: adjusted HR, 0.77; 95% CI, 0.63-0.95; P?=?.02). The increase in all-cause mor...
Source: DB's Medical Rants - October 21, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Philosophical musings on tests in medical school and beyond
Yesterday I read the latest “On Being A Doctor” in the Annals of Internal Medicine. The story – Murky Water – tells the story of a classmate who committed suicide after failing step 1 by 1 question. Over the last 12 hours I have pondered this story as well as an article in the same issue titled The MCAT’s Restrictive Effect on the Minority Physician Pipeline: A Legal Perspective.
What do standardized tests tell us? In college, as a psychology major I took a course in Psychometrics. I understand the principles behind designing tests that produce bell shaped curves.
Test scores measure ...
Source: DB's Medical Rants - September 30, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The suffering man resolved
This article Polymyalgia rheumatica vs late-onset rheumatoid arthritis adds some confusion to my previous conclusions.
This abstract continues my confusion – Presenting features of polymyalgia rheumatica (PMR) and rheumatoid arthritis with PMR-like onset: a prospective study
So I am not sure about the final diagnosis because he definitely had characteristics of both. The good news is that both respond to low dose prednisone.
(Source: DB's Medical Rants)
Source: DB's Medical Rants - September 27, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
A suffering man
Around 20 years ago, while I was still doing outpatient medicine, a 65-year-old construction worker came as a new patient with diffuse pain. His story gave many clues.
3 months prior, he was working on construction in the Mobile area. One task of his involved carrying concrete blocks. One day he could no longer grip the blocks because of hand pain. This pain did not resolve with NSAIDs. He had to stop working.
Over the next months he developed more pain including his shoulders and hips. As he walked into the examine room, he was almost shuffling and clearly was uncomfortable. He had already seen 3 or 4 physic...
Source: DB's Medical Rants - September 26, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Some thoughts on clinical judgement
Thus far I have recorded 8 podcasts for Annals on Call, 4 of which have already been published. The term and concept of clinical judgement enters the conversations repeatedly. Each podcast has had a different guest, yet in most of these conversations I have heard clinical judgement invoked. What is clinical judgement? Do we just use the term when we want to stray from protocol or algorithm? I found this definition which gets us part way to an understanding.
For purposes of description, it can be considered the sum total of all the cognitive processes involved in clinical decision making. It involves the appropria...
Source: DB's Medical Rants - September 20, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
@orangetheory – my 3 year anniversary
Early this morning I attended another great OTF class. 3 years ago my daughter took me to OTF. My schedule that fall was incredibly busy, so it took a few months for me to go “all out” for OTF. My addiction started slowly, but within 6 months I was gung ho. And since then I have attended class around 4 or 5 times each week.
To this day, I have not tired of OTF. The workouts challenge me daily. They work. At age 69 I am in better physical shape that in my 40s.
I joined as a runner – used running and diet to lose 40 pounds started May 2013 and finishing May 2014. I knew that I could become a...
Source: DB's Medical Rants - September 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
My approach to acute pharyngitis 2018
First, we must define acute pharyngitis – no more than 3-5 days of symptoms.
Second, we should understand that pre-adolescent pharyngitis has major differences form adolescent/you adult pharyngitis.( Mitchell, M. S., Sorrentino, A., & Centor, R. M. (2011). Adolescent pharyngitis: a review of bacterial causes. Clinical Pediatrics, 50(12), 1091–1095. http://doi.org/10.1177/0009922811409571 ) Here are the differences:
Pre-adolescent pharyngitis really is group A strep vs viral
Adolescent pharyngitis has a much broader differential – GAS, Group C/G strep, Fusobacterium necrophorum, infectious mononucleosis...
Source: DB's Medical Rants - September 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
db ’ s anion gap pearls
This article describes the precise formula. We use albumin times 3 as a reasonable estimate. (Source: DB's Medical Rants)
Source: DB's Medical Rants - August 27, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Show respect for how hard your interns and residents work
As we age, we look back and convince ourselves that we were better and worked harder than the current generation. Dr. Gurpreet Dhaliwal addressed this issue beautifully in an essay – The Great Generation
Today’s trainees are every bit as professional, motivated to learn, and devoted to their patients as previous generations. Students and residents follow duty hours but then log on from home to monitor their patients, write orders, and stay in touch with their on-call colleagues.7 They come to the hospital on their mandated days off for family meetings. They connect with their patients despite unprecedented paper...
Source: DB's Medical Rants - August 24, 2018 Category: Internal Medicine Authors: rcentor Tags: Attending Rounds Source Type: blogs
The focus of rounding
A wonderful senior resident helped me understand this goal of rounding. Rounds should focus primarily on understanding the key problems and the diagnostic and therapeutic approaches to those problems. She suggested that some rounds spend too much time on “minutia” that the resident could handle, and not enough on understanding the big issues. According to her, rounds work best when we spend our time addressing the problems that the patient has and increasing the learners’ understanding of those issues.
Her understanding of different rounding styles highlights a key question about rounds and graduate...
Source: DB's Medical Rants - August 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Annals On Call – a new podcast
I am delighted to announce that you can listen to the first episode of our new podcast – Annals On Call.
The first episode is titled – The Gout Wars.
These podcasts will have a length of approximately 30 minutes. In them I discuss an Annals of Internal Medicine article with an expert (sometimes one of the authors). We go into depth to understand the article and its implications.
I have already recorded 8 episodes. They will come out twice each month. Of course I will always tweet releases.
We started planning this podcast over 1 year ago. I started recording around 4 months ago.
Many of the episodes d...
Source: DB's Medical Rants - August 7, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Keeping up – the value of twitter
Over the years, many students and residents ask me – how do you keep up? For many years I had no good answer. However, for the past 5 years I have increasingly depended on twitter to clue me in to important new studies.
I use other inputs – skim Journal Watch each day, listen to podcasts, check the NY Times health section and subscribe to NEJM Journal Watch. But each day someone who I follow on twitter will clue me in to an important article.
Most readers of this blog are on twitter, and I would be interested in your opinion on twitter as a trigger for “keeping up”.
(Source: DB's Medical Rants)
Source: DB's Medical Rants - August 6, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
On teaching clinical reasoning – all about case conferences
When we studied ward attending rounds, the thought process represented the top attribute that learners valued. Learners can learn facts from textbooks, but using those facts requires experience and role modeling.
I have given many lectures on clinical reasoning and I have attended many lectures on clinical reasoning. These lectures can entertain, but one lecture does little to help our colleagues and our learners.
We must structure case conferences as a primary way to teach and learn. Lectures may help occasionally, but often the information in a lecture leaves our memory quite rapidly. But a case discussion gives ...
Source: DB's Medical Rants - July 31, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Are useful notes in our future – the return of SOAP
CMS is changing note requirements, among other changes. Bob Doherty has a wonderful summary – FOUR things you should know about Medicare’s “historic” changes to physician payments
As always, we really will have a difficult time sorting out the unintended consequences of these changes, but they certainly seem like a move in the proper direction. To me the most important change is a focus on notes – “allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented ...
Source: DB's Medical Rants - July 16, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
