Robert Centor, MD

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

Direct primary care: Solution or problem?

Physician

February 1, 2017

Longtime readers know of my fascination with the affect heuristic. Simply stated, we overvalue the benefits of a concept that we like, and underestimate the problems or vice versa.

This article about direct primary care induces conflicting analyses: “Here is the PCP crisis solution, and it’s simple.”

I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. …

Why this physician chose internal medicine

Robert Centor, MD

Physician

December 7, 2016

On November 1973, I had an epiphany. My first week on my internal medicine clerkship, I realized that I had found my specialty: internal medicine.

Prior to medical school, I had worked with emotionally disturbed children in an inpatient hospital. I really enjoyed the experience, and learned a great deal. During my first two miserable years in medical school (I disliked how they taught the basic sciences and even more how …

There’s something missing in the doctors vs. AI debate

Robert Centor, MD

Physician

November 17, 2016

Over the past two days, listening to separate podcasts, I have heard the same story and now have a better understanding of artificial intelligence. A Freakonomics podcast — The Future (Probably) Isn’t as Scary as You Think:

And in general, what’s happened in the past couple of years is the best chess player on this planet is not an AI. And it’s not a human. It’s the team that …

Read more…

There’s something missing in the doctors vs. AI debate

Will someone let doctors actually help patients?

Robert Centor, MD

Physician

November 9, 2016

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. …

Statins as primary prevention: Helpful or harmful?

Robert Centor, MD

Meds

October 18, 2016

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 …

Read more…

Statins as primary prevention: Helpful or harmful?

The art of taking an excellent medical history

Robert Centor, MD

Physician

July 21, 2016

The art of eliciting the medical history requires medical knowledge, cultural knowledge, and many “people skills.” History taking is not science, but rather, art, because it requires interpretation and clarification. Patients with the same symptoms express them differently. A major feature of the art of medicine involves learning how to interpret different descriptions of the same phenomenon.

A few examples might clarify these concepts.

The patient tells you that they have chest …

The importance of listening to the patient before we develop our plans

Robert Centor, MD

Conditions

July 13, 2016

Around 30 years ago, LRZ taught me a most important lesson. LRZ, one of my most fondly remembered patients, was a classic blue collar guy. He had a wonderful, gregarious personality. He had significant systolic dysfunction, yet still worked hard for the city. Amongst other things he did, he shoveled the salt into trucks on snow and ice days. He functioned well most days.

One day he came to see me. …

The conundrum of clinical medicine is what makes it difficult

Robert Centor, MD

Conditions

June 17, 2016

The term, “evidence-based medicine” (EBM), provokes strong feelings from its proponents and its skeptics. I spent a full day recently in discussions about EBM. As the day proceeded I understood that evidence is wonderful when it fits the clinical question, but that too often the clinical question does not, and probably will not have adequate evidence.

We have great evidence for some clinical questions. We all know that ACE inhibitors decrease …

What it takes to be a great doctor: Master the fundamentals

Robert Centor, MD

Education

May 24, 2016

Charles Bukowski once said, “Wherever the crowd goes, run in the other direction. They’re always wrong.”

How does one become a master? What process do we use to have the highest probability of success? Here are some examples.

“Picasso was an extraordinary craftsman, even when measured against the old masters. That he chose to struggle to overcome his visual heritage in order to find a language more responsive to the modern world …

Medical schools owe their students more

Robert Centor, MD

Education

May 14, 2016

Readers know that I believe that servant leadership should inform leadership and management decisions. We who have the privilege of having leadership positions at medical schools, therefore, have as a primary responsibility to our students.

Being a medical student, while a reward and a privilege, is nonetheless a stressful experience. The first two years at most U.S. medical schools have the students grinding through the basic sciences related to medicine. The volume …

Read more…

Medical schools owe their students more

Patients are suffering while physicians are suffering

Robert Centor, MD

Physician

May 2, 2016

Ran into a radiology colleague today. He will retire soon, and was happy to discuss the stress on radiology. I have observed more interpretation errors (or at least I think I have) over the past five years. We now strongly stress that the learners review all films and question radiology reads.

My friend opined that volume expectations have become unsustainable. We order too many imaging studies. When you ask physicians to ramp …

Should cardiologists evaluate their obsession with LDLs and HDLs?

Robert Centor, MD

Conditions

April 21, 2016

This post is purposely controversial. I write it because I believe that mounting evidence suggests that we should encourage “out of the box” thinking about this issue. This post is hypothesis challenging. I may be right, or I may be wrong. I hope we get some debate on my speculations.

The latest blow to the cholesterol hypothesis: “Dashing Hopes, Study Shows a Cholesterol Drug Had No Effect on Heart …

It’s time to instill a positive culture in medicine

Robert Centor, MD

Physician

April 4, 2016

This year marks 33 years of administrative positions in academic medicine. When I first started, I suspect I made many major mistakes. I learned through the time-tested school of hard knocks. As I reflect on my own career, and those whom I have observed, I have come to believe the famous saying, “Culture eats strategy for breakfast.”

Look at ward attending physicians. The same attendings have “good teams” every …

Teaching students should be the primary focus of medical schools

Robert Centor, MD

Education

March 26, 2016

An anonymous medical student has this post on KevinMD — A star medical student feels like he made a terrible decision:

And so, medical students learn quickly how to play this game. We enter noble. We leave jaded. We leave seeing that the smart move is to get out of it. And so the smartest of the smartest, the ones lucky enough to have a choice, go into fields where …

Read more…

Teaching students should be the primary focus of medical schools

A story of how one physician overcame burnout. He is not alone.

Robert Centor, MD

Physician

February 26, 2016

Donald Ross (an obvious pseudonym) has practiced in a medium sized town for around 20 years. I count him as a protege as we worked together during his residency. As a clinician educator, we work with many interns and residents, and sometimes we develop lifelong relationships. Donald Ross and I share a love of golf, ACC basketball (although we root for rival teams), and internal medicine. We periodically communicate through …

Physicians can make a difference. Here are 3 ways they did.

Robert Centor, MD

Physician

February 14, 2016

I read and listen to much fiction. While listening to a fantasy novel, one character verbalizes a most important concept. Every action has consequences. Those consequences are both expected and unexpected. We might predict some unexpected consequences, if we only spend some time to think through the likely impact of that action.

Bureaucrats and politicians have imposed a series of administrative burdens on physicians and patients. We use EHRs that work …

These are the words medical educators should think about

Robert Centor, MD

Education

December 30, 2015

Readers are slowly learning about my admiration for the Farnam Street Blog. The about page describes the blog in this way:

My goal is to help you go to bed each night smarter than when you woke up. I’ll do this by giving you tools, ideas, and frameworks for thinking.

I’m not smart enough to figure all of this out myself. I try to master the best of what other …

Read more…

These are the words medical educators should think about

Humility is key for physician educators

Robert Centor, MD

Physician

December 15, 2015

Clinician educators have the opportunity and responsibility to influence students, interns and residents. While we can have some hubris in our education skills, we must always demonstrate humility in our patient care role modeling.

Dr. Orhan Muren, one of my early role models, often told us to never be “cocky” when taking care of patients. As I recall his admonition, I realize that he was urging us to have true humility.

But …

Read more…

Humility is key for physician educators

Are physicians really to blame for the opioid addiction epidemic?

Robert Centor, MD

Conditions

September 19, 2015

During my training in the 70s, heroin use dominated our substance abuse horizon. We saw many patients with IV drug-related complications. We saw heroin overdoses.

For the next 30+ years, we rarely heard about heroin. Over the past 10 years we have seen increasing opiate abuse, but the opiates came from prescriptions. Over the past 2 years, heroin has once again reared its ugly head.

This article blames physicians for opiate addiction: …

The failed primary care-hospitalist exchange: Who’s to blame?

Robert Centor, MD

Physician

September 6, 2015

Recently, I spent two days in Greenville, SC as a guest lecturer. During that trip, I had time to chat with some hospitalists. During our conversations, I explored a classic problem: the inpatient-outpatient handoff.

Talk with hospitalists and you will discover their angst about getting outpatient information on their admitted patients. Talk with primary care physicians and they echo the angst when seeing recently discharged patients.

Personally, I have experienced both sides of …