The transition between the basic science years and the clinical years in medical school are jarring, mystifying, exhilarating and thought-provoking. Recently, I did an hour conference with approximately 30 medical students. About half started their clinical year five weeks ago, while the remainder have only three weeks left before they finish the year. They gave me permission to share our discussion. We focused on their (and my) observations about the …
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Who can argue against evidence-based medicine? Who can argue with using evidence to develop guidelines? The key to practicing great medicine must involve using the best evidence to guide our protocols.
My son, while in college, was an English major. I remember reading his papers. He often used the phrase “on further reflection.” I often recall that phrase when considering these complex issues.
Frederick Nietzsche wrote, “There are not data, only interpretations.” …
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Now that we no longer have to worry about the SGR, we have a new worry. The law consolidates several measurement tools into one big tool. CMS has declared that it wants to pay for value. The law provides a blueprint for paying for value. The underlying assumption of this approach is that we can define and measure value through measuring quality components.
Can we define health care value through measurement? …
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Many readers know that I favor empiric antibiotic treatment for adolescent/young adult pharyngitis when the clinical signs and symptoms strongly suggest a bacterial infection. I favor narrow target antibiotics and only in the patients with Centor scores of 3 or 4 (and perhaps some 2s when the patient looks very ill). This would exclude over 50 percent of patients from antibiotics.
Most organisms already have developed resistance to penicillin, amoxicillin, and …
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Dr. Wes has written passionately against MOC: ABIM Pleads for Mercy.
But perhaps we should ask first: Why MOC at all?
Contrary to years of propaganda promoted through pseudo-science and journal article citations on the ABIM’s website, might MOC have really been created because the ABIM’s consolidated fund balance dropped 43.2% from $54,009,086 on June 30. 2001 to $30,691,329 by June 30, 2013 while the Standard and Poors 500 index increased 37.7% …
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Maintenance is the process of maintaining or preserving someone or something, or the state of being maintained.
Our certification documents that we have trained (in my case in internal medicine) and that we can pass a test on the breadth of internal medicine knowledge. We accept that the ABIM has developed a test the evaluates our entire exposure to the many diseases and treatments that reflect our patients.
The idea of maintenance of …
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All physicians know the scenario. You want to reassure the patient; the patient wants another (usually expensive) test.
In our new metric age, we may have a conflict between overuse and patient satisfaction. The article provides some hospitalist data: “Hospitalists know guidelines but overuse tests to reassure selves, patients.”
How do we balance making our best evidence-based decisions with patient demands? Some experts will tell us that we really have a communication …
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During the MOC debate that JAMA sponsored, I was asked what I would do if “I were king” of MOC.
As an internist, I believe in first making a diagnosis, then prescribing a treatment. So I have spent time diagnosing my needs as an internist.
When I passed my boards I showed knowledge competency. But medicine changes over time. We have major advances and changes since I took my boards.
Some examples follow:
Did I tell you that I was a big fan of palliative care? Palliative care started around 15 years ago at the VA where I worked. We saw the service evolve. We saw how the palliative care approach improved the quality of both life and death.
Many physicians have not yet accepted or at least understood palliative care. Many physicians use some palliative care principles and believe palliative care is superfluous. …
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The most valuable lesson about teaching that I ever learned occurred in high school. I took my first algebra test. The questions were easy, and I wrote down the answers. All my answers were correct, but I got a B. After each answer, she wrote “show your work.” She explained that while algebra questions start out easy, they become more complex over time. Only through careful understanding of ones thought …
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We all want to practice evidence-based medicine. Yet that phrase is so overused that one must always question the true meaning underlying the use of the phrase.
The first assumption that many make is that evidence is a solid structure without nuance. Yet we can have different experts look at the same evidence and develop different conclusions! Why else would we have competing guidelines. Consider this quote from Nietzsche: “There are no facts, …
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While driving to work, I listened to Mike and Mike (a radio sports talk show). Mike Greenberg made a wonderful point about his job. He described what they do as “professional over-reactors.” They take every game and extrapolate, sometimes irrationally, about the implications of that game.
Does this remind you of health reporting? A study appears in a serious medical journal, and the press “blows it up” as the next great advance. …
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This New York Times article stimulated thoughts about teaching internal medicine: “Better Ways to Learn“:
In the new book, “How We Learn: The Surprising Truth About When, Where, and Why It Happens” (Random House), Benedict Carey, a science reporter for The New York Times, challenges the notion that a high test score equals true learning. He argues that although a good grade may be achieved in the short term …
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Dr. Danielle Ofri has an important piece in the New York Times: “The Physical Exam as Refuge.” As an outpatient physician, she makes the case that the physical examination provides a special time for the physician to focus entirely on the patient. Is examination time the refuge for the harried physician, and the opportunity to engage the patient in extended conversation about their condition?
While I did outpatient medicine for …
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While running several times over the past week, I have thought carefully about our profession. I cannot imagine having chosen any other profession than medicine, nor any specialty other than internal medicine.
But that is me, is it you?
A medical tweeter than everyone should follow @medicalaxioms had these tweets recently:
If you become a doctor for wealth or prestige, you are going …
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Internal medicine requires knowledge, deduction, and many skills: history taking, physical examination, analyzing diagnosis tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work.
We had a woman admitted to our …
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After 12 years of blogging, I wonder if I should have titled my blog “unintended consequences.” So many rants focus on the unintended consequences that follow from health care policies.
The aphorism (falsely attributed to Samuel Johnson) states, “The road to hell is paved with good intentions.”
Too often our policy makers, be they bureaucrats in government, insurance company managers or guideline creators, think like a chess beginner. They see the …
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Sandeep Jauhar has this wonderful sentence in his New York Times op-ed, “Busy Doctors, Wasteful Spending”: “There is no more wasteful entity in medicine than a rushed doctor.”
And yet physicians are rushed. Dr. Jauhar writes about the payment system driving shorter visits. That problem represents an important component of undesirably short visits, but it is not the only problem.
The electronic health record adds documentation time, as do the billing documentation requirements. …
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FiveThirtyEight had a provocative article: “Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much.”
The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield competing guidelines. We all know the controversies over breast cancer screening and prostate cancer screening. Recently blood pressure targets and lipid management have …
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Change causes distress for most people. In medicine we have a hierarchy that disdains most change. Medical students, residents, attending physicians all seemingly reject change. Practicing physicians dislike change. Yet change occurs and is necessary. I learned a great deal about change from my mother. This anecdote may help put change into perspective.
Many years ago, we lived in a 3 bedroom house. In the evening we all sat in the …
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