Robert Centor, MD

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

We have performance measures based on rather weak evidence

Physician

April 25, 2014

Recently, we had a wonderful reception at the American College of Physician’s Internal Medicine 2014. Sitting with leadership colleagues we had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century.

Consider the Sippy diet, the Bilroth II, highly selective …

Applying the 5 pillars of success to medicine

Robert Centor, MD

Physician

April 17, 2014

Readers know that I went to the University of Virginia as an undergraduate. Since graduating in 1971 I have remained a huge sports fan and academic fan of the university. Those who follow my Twitter account have seen me tweet often about the basketball team.

Our coach, Tony Bennett, took his 5 pillars of success from his father, the famous coach Dick Bennett. While these pillars have a Christian origin, I …

Developing bedside manner comes from understanding who the patient is

Robert Centor, MD

Physician

April 1, 2014

Over the years I have strived to develop my bedside manner. On rounds many learners comment on this aspect of my doctoring, and these comments have led to much self reflection. This commentary may convince some readers that I have the answers, but I do not. Sometimes I do very well, but sometimes my skills fall short. I do try to connect with patients and families, and give them confidence, …

Patients do not always arrive with diagnoses

Robert Centor, MD

Physician

March 24, 2014

I recently presented my diagnostic talk — Learning to Think Like a Clinician — at the Virginia ACP meeting. Afterwards several physicians wanted to discuss the reasons for diagnostic challenges. They convinced me that many regulations from CMS and other insurers have influenced policies that increase anchoring and diagnostic inertia.

When the emergency department physicians admit to the hospital, they have to give an admission diagnosis. At least in the United …

Demand to become an old school attending physician

Robert Centor, MD

Education

March 17, 2014

“Old school” is difficult, but doable for teaching attendings. While prioritization is the key, having a basic framework will help.

Here are my personal keys:

1. Sit at the bedside and retake the history of present illness on those patients in whom taking the history is clearly a key. For example, someone admitted with presumed community acquired pneumonia should have a short history including fever and perhaps night sweats and possible rigors. …

One physician’s story of weight loss

Robert Centor, MD

Conditions

March 10, 2014

Having now lost more than 30 pounds, I am very close to declaring victory (maybe a few more pounds over the next few months). A colleague has asked me to write my tips as a handout for patients. This is a daunting task, but that has never stopped me!

The weight loss formula is simple and well known. Achieving lasting weight loss remains challenging. The mathematical formula is simple. Weight loss …

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One physician’s story of weight loss

Solving the physician income disparity

Robert Centor, MD

Policy

March 3, 2014

As an internist (yes, I am a specialist, just not a subspecialist), I do no procedures. Patients pay me (albeit mostly indirectly) for my cognitive skills. But we live in a culture that seemingly rewards procedures more that pure cognition. Now I understand that procedures are not mindless. Physicians doing procedures must think prior to the procedure, during the procedure and after the procedure. But cognition without procedures seems undervalued.

The …

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Solving the physician income disparity

A cognitive error when treating adolescent pharyngitis

Robert Centor, MD

Conditions

January 30, 2014

Since prior to my entrance to medical school, common wisdom for treating sore throats involved the prevention of rheumatic fever. Since group A strep pharyngitis is the cause of most acute rheumatic fever, all efforts have focused on treating group A strep. Studies in the 1950s showed that penicillin treatment decreased the probability of patients developing rheumatic fever.

The prevailing theory in the 50s and 60s, that we should diagnose group …

Scut work takes away from a physician’s inherent joy

Robert Centor, MD

Physician

January 20, 2014

Most physicians love the profession. Our medical students and residents want to care for patients, interact with patients and help those patients. For most physicians, the joy of medicine occurs at the bedside and while investigating patient problems. The joy does not extend to scut work (defined in the free dictionary as “trivial, unrewarding, tedious, dirty, and disagreeable chores”).

Now who defines scut work?

Back in the 70’s, we would define scut …

Thoughts on the new blood pressure guidelines

Robert Centor, MD

Conditions

January 3, 2014

The new blood pressure (BP) guideline, released recently in JAMA, has simplified blood pressure management and likely decreased both the number of patients needing treatment and the number of medications they need. Many commentaries have begun to flood the Internet, so of course I must add my thoughts.

First, please read Harlan Krumholz thoughts: 3 Things to Know About the New Blood Pressure Guidelines.

Here are my main thoughts:

1. This guideline panel commissioned …

Restricting resident work hours decreases deliberate practice

Robert Centor, MD

Education

December 25, 2013

Pauline Chen has once again written a brilliant piece in the New York Times: Are Today’s New Surgeons Unprepared? While many comments miss her underlying question, her exposition makes the problem clear.

How do we gain expertise? Current theory supports the idea of deliberate practice. How do we conceptualize deliberate practice? Start with a sports analogy. You are trying to learn to make a 6 foot putt. In scenario …

The bureaucracy that has engulfed medical education

Robert Centor, MD

Education

December 16, 2013

While my career has included patient care, research and administration, I have always considered medical education my primary purpose. Having had the great opportunity to know many students and residents, having had the great opportunity to visit many medical schools, and having had wonderful colleagues, I have great concerns about the bureaucracy craze that has engulfed medical education.

This morning I spent a few minutes reading tweets, and came across a …

Why the independent payment advisory board is a good idea

Robert Centor, MD

Policy

December 9, 2013

The independent payment advisory board (IPAB) is a key feature of the ACA. This board will do what many countries already do — have an independent expert panel to assess the effectiveness of procedures, imaging studies, pharmaceuticals, etc.

Why do we need this board? We need careful assessments of new trends in medicine.

Let me suggest two situations.

We have read much about increasing colonoscopy costs. We have a controversy about anesthesia — …

The cholesterol debate: Seeking truth where there is no truth

Robert Centor, MD

Conditions

November 25, 2013

The New York Times recently had one of their periodic debates: When Medical Experts Disagree.

This debate actually centers on the current cholesterol guidelines, but the problem recurs often. Different experts look at the data and develop differing opinions. We see this with prostate screening, mammography, and treatment decisions.

As one reads the varying opinions in this debate, an understanding of the affect heuristic makes the debate transparent. When we like …

The idea of RVUs disgusts me

Robert Centor, MD

Policy

October 23, 2013

Blaming the American Medical Association’s Relative Value Scale Update Committee (RUC) for everything has become the latest fashion. The RUC is causing climate change. The entire health care cost problem comes from RUC decisions. Alex Rodriguez took performance enhancing drugs because of the RUC.

But the RUC did not create the system. They try hard to balance a system that is designed to achieve the wrong outcomes. The RUC has become …

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The idea of RVUs disgusts me

6 thoughts after testifying at a medical malpractice trial

Robert Centor, MD

Physician

October 3, 2013

A few weeks ago I was an expert witness in a malpractice trial. In this post I will use generalities and specifically not reveal any details of the patient or the court case. I first became involved in this process several years ago. My involvement included a deposition, reviewing medical records, reviewing other expert depositions, discussing the patient’s most unfortunate story with lawyers for two different defendants, and finally testifying. …

Don’t blame millennials for the drop in board exam pass rates

Robert Centor, MD

Education

September 23, 2013

You have to love the blogosphere. The latest big issue concerns lower ABIM pass rates. Here are a series of blog posts worth considering.

Dumber Doctors?

One concern that has a ring of truth to it is that young doctors have become great “looker-uppers,” and have lost the sense of what it’s like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, …

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Don’t blame millennials for the drop in board exam pass rates

We must demand a return to meaningful notes

Robert Centor, MD

Physician

August 30, 2013

I had a nice conversation with a dermatologist at a party recently. He started complaining about the notes he receives from other physicians. He used terms like piles and piles of junk.

Talk to any experienced physician and they will tell you that once upon a time our teachers taught us to write notes appropriate to the situation, not appropriate to the billing system.

Several years ago I ranted about the necessity …

We need to reassess the patient note

Robert Centor, MD

Physician

August 16, 2013

I recently tweeted about Danielle Ofri’s important piece, The Doctor Will See Your Electronic Medical Record Now. I like the piece, and especially like some of the quotes, but still I believe the problem needs an expanded take.

Context represents the major advantage of 38 years experience as a physician. Over time, one sees trends come and go. Hopefully one can see the strengths of the “good old days” and …

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We need to reassess the patient note

Reminding medical students and residents to shake off the cynicism

Robert Centor, MD

Education

July 30, 2013

Attending physicians have great responsibility. We have ultimate responsibility for patient care and for medical education. Medical education involves sharing facts, the thought process and bedside manner.

Recently we had a “frequent flyer” admission. For a few years, the housestaff labelled this patient as non-compliant – and even wrote it in his chart. He is young (less than 30) and has a chronic disease. He had multiple admissions and often left …

Robert Centor, MD

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