There are few aphorisms in medicine that stand up to reality. Here are two: Physicians get the patients they deserve, and we tend to die like we live.
Paul Kalanithi’s posthumous memoir proves both: As a neurosurgery resident at Stanford, he took on the most challenging cases, and when diagnosed with terminal lung cancer, he lived and died pursuing excellence and truth. I read When Breath Becomes Air on …
The holy grail of clinical reasoning is, in a word, assessment. Ought we to measure clinical reasoning as a function of experience, knowledge base, or as a process measure? In medical parlance, there is no “gold standard.”
In 2015, to tell whether your doctor is a great diagnostician is based more on reputation than hard evidence. This gap in evidence is all the more interesting given recent press about the inattention …
Searching for the holy grail of clinical reasoning
Mr. J was as close to a typical sixty-year-old patient as possible, wary of doctors and selective in when he took his blood pressure medications. On a sunny Thursday, he woke up nauseated and called an ambulance. During evaluation in the emergency room, his blood pressures reached atmospheric levels (nearly 300 systolic). He began seizing, which soon stopped and was transferred to the ICU. As the admitting resident, I dutifully …
The price of certainty in the ICU
It’s a Monday morning, and two patients wait expectantly for the cardiologist. Instead, they get me, a fresh resident. “I don’t know why I’m seeing you,” says the first. I bumble through the chart and find a note indicating he has a large atrium on his most recent echocardiogram.
“So, what surgery do you have coming up?” I offer, to get …
Are preoperative consultations worthless?
I recently gave two talks at my residency program, one on health care innovation and another on intimate partner violence. I know little about each topic, but my goal as presenter was merely to know more than each person in the room. To require residents to give talks as newly-minted “experts” on topics creates a paradox of generating both anxiety and …
Our feedback model is broken. Here’s how to change it.
As an internist, working in the emergency room feels at times like the dark underbelly of medicine. The frenetic pace, the need to make decisions within highly uncertain conditions, and reliance on technology all cut against the grain of the internists credo of “being a doctor’s doctor.” If internists are biased in how they arrive at diagnoses, emergency medicine doctors face such bias on an exponential scale. Clinical decision-making is …
Confronting cognitive bias in the ER
I recently took another survey confirming the obvious: As a resident, I am horribly burnt out. I sat, along with a half-dozen health care providers and bemoaned our current states. What, if anything, can we do about this? The typical answers came up: sleep more, increase our commitment to enjoyable activities outside of work. Oddly enough, there was little talk about the daily work itself, and how the medical culture …
Want to decrease physician burnout? Stop blaming the victim.
In a recent grand rounds on the future of medicine, the buzzwords were “collaboration” and “managing of the health of populations.” The same day, a group of ten residents were presented with their patient data about cancer screening rates. In both venues, the call to “population health” elicited sighs of exasperation. It’s just another checkbox we are being asked to click off. How can we be assessed on that as …
How to make outpatient population health more exciting
On a 12-hour shift in the hospital, I recently spent a mere hour with patients, with the rest glued to a computer screen, to the “iPatient.” When a patient comes to the hospital, speaking to them has become an afterthought to reading extensive medical records, physical exam findings from the emergency room, and synthesizing laboratory data. I, as a millennial doctor, have been on the cusp of this shift. My …
Do electronic records change the way doctors think?
What we are trying to do is create a system that gets rid of the human factor.
– an internal medicine physician
I heard this statement in a patient safety seminar designed for medical residents. I paused, shuddered even, as a resident who writes poems and reads novels in my free time. To my surprise no else blinked an eye. And why should they? The concept that physicians’ humanity and empathy shape health …
A factory model of health care can only go so far
No medical resident looks forward to working night float. The initial glamour of doing chest compressions in the rising light comes up against a litany of administrative tasks. As the glamour wanes, the gulf between the objective curriculum and actual practice widens. On paper, residents learn how to manage acute emergencies and learn deeper clinical reasoning. Actual practice, or the “hidden curriculum” of training, can be a different experience, involving …
Learning from the lessons of night float
Despite recent buzz about shifting resident education to community health centers, hospital based education is here to stay. The model of education, though outmoded, is simple. Get residents exposed to as much disease as possible, in the shortest amount of time. The future of American health care is not in acute management of tertiary care; but in integrated, team-based care. To get there involves focusing not only on educational content, …
Is deep learning in medical education possible?
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