My descent into guideline fatigue syndrome (GFS)
It started slowly. My former resident and present colleague, Terry Shaneyfelt first authored Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature
This paper alerted us to the problem. But guideline fever continued to rage. Almost every specialty and subspecialty society decided that they needed to join the guideline movement. They needed to tell us the RIGHT way to practice medicine.
While I understood the problems of guidelines (I had found a 40 page guideline on cerumen), it had not yet become visceral. Then the great pharyngitis...
Source: DB's Medical Rants - December 25, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
More on sepsis
A great comment from Dr. Cory Franklin:
As an ICU physician and one of the people who drafted the initial “Sepsis guidelines” in 1991-1992, I want to point out they were not drafted with the intent of clinical use, rather as study criteria for the evaluation of sepsis drugs, in that case Xigris (unsuccessful).
i was one of the people who said that they should not be used as clinical criteria, since the whole concept of sepsis is ill-defined and difficult to validate. This fell on deaf ears and within a short period of time I saw ER diagnoses of R/o SIRS. IT soon became a routine clinical diagnosis, even though it was n...
Source: DB's Medical Rants - December 20, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The IDSA takes an admirable position in not endorsing the new Sepsis Guidelines
This article explains wonderfully the problem of guidelines. Confirmation bias will impact all guideline panel members. As you read the IDSA explanations, you can see that they have focused on the unintended consequences of markedly increasing sensitivity and therefore markedly decreasing specificity. The reference for the IDSA article (abstract only unless you have access).
The main points are found in the report – IDSA withholds support for international sepsis guidelines
The IDSA’s major concern with the guidelines is that they fail to recognize the “practical difficulties” in diagnosing sepsis. The ...
Source: DB's Medical Rants - December 18, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Ward attending notes to my younger self
Finishing my 38th year of internal medicine ward attending, I wish I knew then what I know now. I estimate the equivalence of at least 10 full years of ward attending, I think this meets the magic 10,000 hour number. Hopefully, these notes to myself will help some newly minted ward attendings. The job is quite difficult and multifaceted.
Understand the various responsibilities of the ward attending
Help your learners grow
Make certain the patients get top notch care
Be a good role model for the learners
Stay healthy, both mentally and physically
Never lose your humanity
What distinguishes ward attending is teach...
Source: DB's Medical Rants - December 16, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The Emperor of Performance has no clothes
Our greatest and worst attribute is seeing and saying that the Emperor has no clothes. It requires intellectual honesty, a willingness to overcome confirmation bias and perhaps some hubris. Often we make others uncomfortable with the raw honesty of such proclamations.
For years many blogs have decried performance measures. I have written about this problem for over 10 years. Currently I serve on ACPs performance measure committee. In this capacity I have reviewed well over 100 performance measures. Most performance measures have the potential for harming patient care. The committee has given a thumb down to m...
Source: DB's Medical Rants - December 9, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
On setting achievable goals for behavior change
Long time readers know that I lost approximately 40 pounds in the year starting with Memorial Day 2013. When I started, I did not have a big goal, rather I had a small goal. The day I started, my goal was to lose 8 pounds. After losing 8 pounds, I made a 5 pound goal.
Friends and family asked me how much I planned to use. I refused to set a goal that could frustrate me, rather I set achievable goals.
As I achieve each goal, I had the opportunity to consider a new goal. I was able to reward myself with new clothes as my sizes decreased consistently.
I developed a reasonable plan – increased cardiovascular ex...
Source: DB's Medical Rants - December 3, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
May physician targeted performance payment finally receive its death toll
Long time readers of this blog know my disgust with pay for performance. P4P has many incarnations, all of which are harmful to patients and physicians. The blogosphere has ranted about this for at least 11 years. Search P4P on this blog and you will see the vast number of posts regarding this topic.
This week’s Annals of Internal Medicine has a wonderful article and editorial that strongly indicts “value based payment”:
Value-Based Payment Modifier: Outcomes and Implications | Ann Intern Med | ACP | http://bit.ly/2irAneF
Changing How We Do Pay for Performance | Ann Intern Med | ACP | http://bit.ly/...
Source: DB's Medical Rants - November 30, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Thanksgiving Challenge 2017
For many years I set a Thanksgiving Challenge to myself. The goal was to lose weight between Thanksgiving and New Year’s. It was a resolution.
This year I do not need to lose weight. So my goal this year is to maintain.
My personal plan is to continue working out regularly throughout the month of December. I need to eat intelligently.
So my challenge to you: at least maintain your weight, and if you need to lose, start your journey now. Do not wait until New Year’s Day. Start now.
Losing weight is difficult but doable. Portion control and exercise are the keys. Learn to eat a bit less. Put l...
Source: DB's Medical Rants - November 26, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
When to give bicarbonate for metabolic acidosis – increased versus normal gap acidosis
Last week I posted a list of topics that we discussed during a 5 day period of rounding. I was asked to share my teaching points.
We had 2 patients, one who had a normal gap acidosis and one who had an increased anion gap acidosis at admission. The team did not treat the normal gap acidosis, but did treat the increased anion gap acidosis. They got it backwards.
This is actually quite straightforward. Normal gap acidosis always deserves treatment, while increased anion gap rarely requires bicarbonate. Sabatini, S. and Kurtzman, N.A., 2009. Bicarbonate therapy in severe metabolic acidosis. Journal of the American Soc...
Source: DB's Medical Rants - November 21, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Being a physician – lessons learned from Harry Bosch
I just finished listening to the latest Michael Connelly mystery – Two Kinds of Truth. His main character in many books is Harry (short for Hieronymus) Bosch. Bosch is a police detective who epitomizes characteristics that we see in the best clinicians. Here is a compilation of what I find in this novel as well as his previous novels.
Harry Bosch focuses on justice for the victim. Great physicians worry about the patient first. They want to make the proper diagnosis and provide the most appropriate treatment for their patient.
Harry Bosch is guilty of framing, but will recognize his mistake. In this book...
Source: DB's Medical Rants - November 19, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Things we discussed last week on rounds
Each week on rounds several very interesting topics arise. In December I plan to discuss these issues on a daily basis, but today I am reflecting on 5 days of ward rounds last week. I just plan to list some issues, not include the discussions or why we focused on those issues. Please feel free to ask questions or request a longer post on an issue.
When to give bicarbonate for metabolic acidosis – increased versus normal gap acidosis
How you can have both a metabolic alkalosis and acidosis at the same time
When to aggressively evaluate an anion gap acidosis
What is community acquired pneumonia and when should w...
Source: DB's Medical Rants - November 13, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM attendings – Chapter 20 – why we ask questions
I had a wonderful dinner with some medical students last night. Earlier in the day at morning report I had asked them multiple questions. Given the ongoing debate over pimping (a debate that will likely never end), I asked them to reflect on the questioning.
They had several thoughts (all positive) and during the discussion I started to understand better the power of questioning. As attending physicians we should ask questions. I often frame the questioning as a process for determining what we should discuss. If the learners know the answers, then further discussion may be a waste of time. If they do not know, ...
Source: DB's Medical Rants - November 9, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The neverending IM rounds debate – what is the best style?
I could stop with one sentence – there are several styles that work. Let me explain.
Internal medicine rounds have several goals. First, we owe our patients the best diagnostic evaluation and then the best care. We owe our patients careful explanations of the day’s plan, and the overall plan. Too often we have to break bad news.
But we also have an obligation to help our learners grow. They want to understand what we are doing and why we are doing it.
Our group published an important paper Using Cognitive Mapping to Define Key Domains for Successful Attending Rounds While the paper and methodology may...
Source: DB's Medical Rants - November 5, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The major medical issues of 2017
Periodically we should reflect on what challenges face patients and physicians. Over the past few days I have worked on a list of the issues that concern me the most. I welcome suggestions for expanding the list.
Diagnostic errors – all patient care requires that we make the proper diagnosis. Too often we make errors. A recent paper estimated that 30% of cellulitis admissions did not have cellulitis. A similar paper found almost the same estimate for community acquired pneumonia admissions. The most common reason for successful malpractice claims is diagnostic errors. Have they increased? Members of ...
Source: DB's Medical Rants - November 3, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The story of the FeNa test
Previously published at Centor’s Corner (an MDCalc blog)
September, 1976: I was a 2nd year internal medicine resident at the Medical College of Virginia.
My attending physician, Dr. Carlos Espinel, had just published a now-classic article: The FENa test.
So that month, I had the wonderful opportunity to understand the rationale behind a test that I now have used for over 40 years.
To understand the test, one must first understand the assumptions. Dr. Espinel defined clearly that one could use this test to help differentiate between volume contraction and acute tubular necrosis (ATN) in oliguric patients. H...
Source: DB's Medical Rants - October 24, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
