MKSAP: 41-year-old woman with burning epigastric and chest pain

Conditions
April 7, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones. The pain resolved with administration …

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If you go to medical school, you will be stressed: bigly

Education
April 6, 2018

Two recent posts highlight the problems facing many medical students today.

The first was by an anonymous rising fourth-year student who has come to the conclusion that going to medical school was “a terrible, terrible decision.” It ended with a comment that medical school “is not fun. It’s jarring, scary, disappointing and absolutely depressing.”

The second was by another anonymous student who described how miserable he (or she) has been …

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The unintended meaning behind medical schools’ pass-fail system

Education
April 6, 2018

In recent years, there has been a push across medical schools to change the grading scale towards that of a pass-fail system. The appeals of a pass-fail system to me were obvious. Instead of worrying about my grades as I had in college to maintain an adequate enough GPA to get into medical school, I believed that merely passing would lessen much of the pressures I faced as an undergrad.

Those …

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When you leave primary care, you leave people behind

Physician
April 4, 2018

“The ones you leave behind …”

That phrase often connotes loved ones who have lost a family member, friend or colleague through death.

I have thought of the same phrase often lately in a different context — one of increasing prevalence.

Here, I refer to the patients and colleagues left behind by the loss of a primary physician.

No one would begrudge the retirement of a physician who has served his or her patients …

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Physicians must learn to say no

Physician
April 4, 2018

As a physician, is it acceptable to say no? After working as a hospital medicine physician across five different states and internationally, I’ve realized that saying no is actually imperative. Physicians are stretched thin, abused, demonized and expected to be superhuman when it comes to patient care. We secretly complain in online forums, we commiserate with other physicians in on-call rooms, sometimes we even seek mental health help, but rarely …

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Doctors wear white coats. But what do their spouses wear?

Physician
April 4, 2018

When we first met and got married, my husband Josh wanted to be a math teacher. Since I was also pursuing a career in teaching, I thought this was a great idea. I envisioned both of us teaching together in the same school district for forty years, becoming local superstars! We would know all the kids in town and spend our summer vacations traveling to exotic locations around the globe. …

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Is surgical training stuck in the past?

Physician
April 4, 2018

When we look back on the last century, the pace and number of advances in our ability to treat disease and injury is truly astonishing. The exponential growth of technology has contributed to this greatly, as we see new advances often come in the form of new technologies. Amazing innovations in the fields of endoscopy, catheterization, robotics, imaging, navigation, 3D printing and more allow us to do things that were …

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How to do risk-adjusted diagnosis coding the right way

Policy
April 3, 2018

Medical practices with risk-adjusted contracts must sharpen their diagnosis coding. Practices that are part of accountable care organizations (ACOs) or that have risk-adjusted contracts with commercial payers have an economic incentive to accurately report the disease burden of their patients. In fee-for-service medicine, physicians are paid based on the fee schedule associated with a CPT code, and any modifier attached to that code. The diagnosis code establishes the medical necessity …

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So you missed the bull market. What can you do now?

Finance
April 2, 2018

We are now nine years into the current bull market, and the S&P 500 has risen over 300% from its March 2009 low.

Unfortunately, there are some investors that have been left behind. They sold their stock in 2007-2008 and never got fully back into the stock market. For example, a reader on the Bogleheads forum recently posted this question:

“I have had about $450k sitting in cash for too …

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5 things pathologists want other doctors to know

Physician
April 1, 2018

1. Clinical history is important. What did you see when you took the biopsy?  Was there a mass there?  Does the patient have a history of malignancy?  These are all important questions, and they help pathologists arrive at the most accurate diagnosis possible.  Rarely, the best we can give you is a differential, but the more clinical information given to us, the more likely we can narrow things down and pinpoint …

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The first time this doctor hated a patient. And what he did next.

Physician
March 31, 2018

“Dr. WHAT?!” she spat.

“Gold … man. Gold, like the precious metal, and, y’know — a man.” This carefully crafted response was curated and vetted by countless returned pages, and it rarely failed to produce a chuckle. The patient was not amused, and she referred to me, instead, with a disdainful, “Rosenberg.” Every day I re-introduced myself, and every day — “Rosenberg.”

This 36-year-old female admitted for road rash and multiple rib …

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What should physicians look like? Should it matter?

Physician
March 28, 2018

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that …

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An emergency physician delivers a baby, and realizes that it isn’t for him

Physician
March 27, 2018

I’m an emergency physician. In common parlance, an ER doc. Which means, like a little kid who will eat dirt on a dare, there’s not much I won’t try in the practice of my profession. Many of my colleagues have had far more challenging careers than me, I assure you. But I have some stories to tell. Cyanide overdose while moonlighting as a resident. Patient nearly dying from bite by …

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Clinical plagiarism: the problem of copy and pasting in EMRs

Tech
March 26, 2018

It is all too common for a section in a progress note to look something like this:

# Aspiration pneumonia:

  1. Continue vancomycin 1 g bid
  2. Continue Zosyn 3.325 g q6h
  3. Follow-up blood cultures
  4. Follow-up sputum cultures
  5. MRSA nares screen negative
  6. Blood cultures negative
  7. Discontinue vancomycin

Yesterday, a version of this note (lines 1 to 5 to be precise) had my name on it. Today, it is signed by someone else. Read it …

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Learn typical community acquired pneumonia with a Medcomic

Conditions
March 26, 2018

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside of the hospital or less than 48 hours after hospital admission. CAP is classified into typical and atypical subtypes, differentiated by their presentation and causative pathogens. This illustration focuses on the classic features of typical CAP.

The most common cause of typical CAP is Streptococcus pneumoniae. It is an encapsulated, gram-positive, …

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The medical student who cries

Education
March 25, 2018

I’m a default crier. I happy-cry, stress-cry, romantic-comedy-cry, regular-comedy-cry and, apparently, I even doctor-in-training-cry.

Crying is a tough response, especially for someone who wants to take care of sick patients. My default reaction poses challenges for my future career. I had my first taste of this when a patient actor brought me to tears. An actor? That’s ridiculous, you might think. It was all pretend and yet, I broke down. I’m …

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A physician is often the only person that sets the tone of hope, or despair

Physician
March 24, 2018

It was mid-afternoon in the ever-bustling surgical intensive care unit (ICU). The nurse, one of those experienced, battle-hardened savants of human symptoms, called me into one of the patient rooms. He was tachypneic on the ventilator with labored breathing and declining oxygen saturations; with each inspiration, his diaphragm would paradoxically elevate, his stomach bulge and the ventilator alarm with the dyssynchrony. Intubated, sedated and unaware, he was fighting for his …

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