American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, May 25, 2016

Tips for clinician educators and aspiring clinicians

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 is an important triumph that has had a vast effect upon our world. (from Picasso's Early Work)

Great musicians practice their scales and learn their chords. They play different time signatures. Only then can they tackle jazz or classical mastery. And yet they continue to practice the fundamentals regularly.

Success doesn't necessarily come from breakthrough innovation but from flawless execution. A great strategy alone won't win a game or a battle; the win comes from basic blocking and tackling, said technology entrepreneur Naveen Jain.

So what is my point? Why have I started this rant with a series of quotes and statements about fundamentals?

Too many students, residents and attending physicians fail to work on mastering the fundamentals. What are the fundamentals? At the risk of being pedantic, this is my personal view.
• Learning to take a careful and complete history of present illness. While this seems straightforward, the art involved takes much practice and much knowledge. Without knowing at least basic differential diagnoses, one will not explore carefully enough. One can only improve this skill through deliberate practice. We also must understand that questions about a patient's history of present illness should not end at the time of admission, but rather continue as we gain more information.
• Learning the fundamentals of the physical exam. While some argue that the physical exam is dead (or dying), I still see patients for whom a physical exam finding focuses our evaluation and sometimes helps make a diagnosis.
• Learning how to interpret all the routine blood tests. We spend money on these tests, and yet too often learners and physicians do not really focus on the lab tests or now what to do with an abnormal result.
• Look at our patients' X-rays and ask about findings that bother us.

Many newly minted attending physicians either do not really know the fundamentals, or do not understand that their learners need the fundamentals more than they need to learn the esoteric. Too often residents choose weird patient presentations for morning reports, when they really need to dissect carefully the common.

As attending physicians we often erroneously assume that residents have mastered the fundamentals. But while some have, many have not. We rarely go wrong when we discuss physiology, pharmacology or anatomy that relates to the patient's problem. Even the best residents benefit from a careful discussion of why the serum sodium is high or low, why the bicarbonate level is abnormal, or why the patient has few lymphocytes. Even the best residents benefit from discussing bedside manner, history taking or demonstrating a physical finding.

So my advice is to work constantly to master the fundamentals, even when you exploring the more esoteric. We can only explore new insights accurately when they are based on these fundamentals.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Tuesday, May 24, 2016

A doctor that every patient would want

The practice of medicine has changed dramatically over the last couple of decades, with many of the changes unfortunately not so good for patients. It's a well-known feeling among health care professionals, that among all the new elements of bureaucracy and information technology requirements and mandates, the one person who is often completely forgotten about is the patient.

As someone who has worked up and down the east coast in every type of hospital over the last several years, I am witness to that unfortunate truth. We always tend to forget the patient. With that in mind, I have gotten a real sense of what patients value and desire from their physician. Here is what I suspect those “dream doctor” traits would be, and what a letter from a patient would look like:

Dear Healthcare Organizations & All Physicians,

Based on my interactions with doctors, here is a list of the things I'd really like mine to be like. I find that most doctors are technically excellent and very competent, and the major issues simply relate to communication. If you are serious about raising the quality of care and improving the health care experience, you may want to take some of these points on board:
Speak to me respectfully and take time to listen to me. Empathy and compassion go a long way, and sometimes just a caring ear can count for an awful lot. Sit down and explain everything clearly to me (and my family if they are also present). Give me a chance to ask questions too.
Following on from the above, please make sure you are on the same page as any other doctors I'm seeing. It really gives me great heart to know you are all talking to each other!
When you are with me, please maintain eye contact. I am really bothered if you keep turning around to your screen to type furiously on your keyboard and click boxes. I am a real person with a story to tell.
Familiarize yourself with my chart and past history before you see me for the first time. Again, this is very heartening and reassuring to me.
Be accessible. If I have a question or concern, it's great to know that I can get in touch with you. I know you are super busy, but even if it's your office staff or a colleague, it should be relatively straightforward for me to relay a concern.
Please make sure that when I leave your care, whether in a hospital or in your office, that my followup instructions are clear and unambiguous. I don't understand technical medical terms. Last time I left the hospital I got a printout of computer gabble that looked similar to the paper I got after my car was serviced—that meant nothing to me and I couldn't understand.
Keep in mind that you are seeing me at one of the lowest points in my life. Those few minutes you spend with me are really important and I'm hanging on every word you say.
Smile more and remember that each patient you see is a real person and not just another name on your list! I have a life and just want to feel well again so that I can back to it.

Many Thanks for the great work you do every day,


Based on the above, here is how a “dream doctor” would communicate (in a hospital):
• You walk into the room and greet me with a handshake and warm smile
• You pull up a chair, sit down and get talking, asking openended questions
• You already know a lot about me (assuming we are meeting for the first time)
• You speak slowly and clearly, avoiding excessive medical jargon
• You maintain eye contact and don't keep turning around to start clicking and typing
• You give me and my family a chance to ask questions
• You summarize everything to me
• You say goodbye and tell me when you will next be seeing me or how I can follow-up

These requests could come from anywhere in America, or indeed the world. The question however, from the physicians' side, is how do we get to a health care environment where these (relatively simple) demands can be met? If physicians simply don't have the time to do these things because for every 5-minute patient encounter there's 20-25 minutes of bureaucracy and IT click boxes, we clearly can't fulfill our patients' wishes and needs.

That's why we need to get back to the drawing board. The doctor-patient interaction is sacred and those precious few minutes transcend everything else and should be every doctor's “zone”. That is something that no mandate, administrator or information technology can ever touch. They are what the patients and families will remember and judge you on. Patients simply cannot just be an afterthought in a real health care system.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Monday, May 23, 2016

How bedside ultrasound was awesome last week

I sometimes do locum tenens assignments as a hospitalist in rural hospitals. It is a good way to find out how other systems work, or don't work, and meet new people and interact with new communities. It's great to be home and also good to go away and come back later. Besides the usual trappings of doctoring, including stethoscope, otoscope, and white coat, I wouldn't be caught dead without my pocket ultrasound.

I just got back from a week of 12-hour shifts in a 48-bed hospital and once again was very happy to have the ultrasound. They do have ultrasonography in the radiology department at this hospital, but echocardiography (ultrasound of the heart) is only available on weekdays from about 8 to 5, and it needs to be scheduled in advance. Also, the ultrasonographers don't necessarily look at the things I find interesting, and can't combine imaging with physical exam findings and what the patient tells me in real time. Patients also really enjoy seeing what's going on inside when we both look at the pictures together. Ultrasound has been part of my usual practice for 4 years now, and you might think it would get old or boring, but it hasn't.

These are a few of the cases in which it made a huge difference to a patient that I had access to ultrasound at the bedside as part of the physical exam:
1. A man came in with a history of heart valve surgery and swelling of the legs. It was not clear how well he took his medication at home, but he was known to have congestive heart failure. He had had a large pericardial effusion with tamponade (fluid surrounding the heart causing it to fail) a few months before I saw him. The bedside ultrasound ruled out tamponade and showed that his heart failure was in pretty good control. He improved impressively with just staying on his regular medication and keeping his feet up. Without the reassurance of the ultrasound I might have given him extra diuretic medication and perhaps caused kidney failure. I also might have had to send him to another hospital for a full scale echocardiogram to rule out tamponade, which would have required an emergency intervention.
2. A person with a long history of alcohol abuse came in feeling generally terrible. After treatment for alcohol withdrawal, he developed very low blood pressure and high heart rate with a low grade fever. Ultrasound of the left lung showed a definite pneumonia, though the chest X-ray visualized that area poorly, missing the pneumonia completely. Having this diagnosis helped considerably in diagnosing sepsis and choosing the right antibiotic as well as ruling out a heart problem as the cause of the vital sign abnormalities.
3. A very old man came in from home with a recent history of bleeding from his urinary catheter due to pulling on it. The family was worried about blood clots obstructing the catheter. A very quick ultrasound reassured them that all was working as it should have been. The patient was saved having the catheter unnecessarily removed and replaced.
4. After a motorcycle wreck which caused rib fractures and a pneumothorax (popped lung) a patient had persistently low blood oxygen levels. She was also a smoker so the differential diagnosis included worsening pneumothorax or simply not breathing deeply due to pain. The little ultrasound detected no pneumothorax so treatment was aimed at improving breathing rather than considering placement of a chest tube. There are many other imaging procedures that could have made this determination, but none of them were instantly at hand when I needed the answer.

Bedside ultrasound is gaining popularity as a tool for internal medicine physicians and hospitalists, but is nowhere near being universally or even commonly a part of our practice. It does take training, practice and the little machine in the pocket or easily available on a cart in the clinic or hospital floor. Truly, these are obstacles, but totally worth tackling.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Zika virus, birth control and abortion

“CDC's Emergency Operations Center (EOC) was activated January 22, 2016, and moved to a level 1 activation—the highest level–on February 8, 2016. The EOC is the command center for monitoring and coordinating the emergency response to Zika, bringing together CDC scientists with expertise in arboviruses like Zika, reproductive health, birth defects and developmental disabilities, and travel health.”
—U.S. Centers for Disease Control and Prevention

“How many people have fallen in the city of Philadelphia by the pestilential infection is unknown to the Author–and he believes to the inhabitants of the same place, for the accounts are very different, as some mention four, others five, six, and even more than seven thousand: and the latter has been supposed to be not too large. Some have given the disorder one name, and others another, etc. It has been called a ‘genuine plague’; a ‘putrid malignant fever’, a ‘Yellow fever …’”
—Stearns, Samuel. An Account of the Terrible Effects of the Pestilential Infection in the City of Philadelphia; … [1793?]. From the Harvard U. Open Collections Program.

Tens of thousands of North Americans died of yellow fever during the first few hundred years of European colonization. The virus, spread by mosquitoes, was probably imported by African slavers: the wages of sin, one might say. In 1878, about 10% of the population of Memphis, Tenn., died of the disease, despite half the population having fled the city.

Even in 18th-century Philadelphia, physicians had recognized that the disease was related to shipping and that it only appeared in warm weather. It would be more than a hundred years until the link with mosquitoes was clear.

Aedes aegypti, the mosquito responsible for spreading the disease, also transmits other nasty viral infections such as dengue fever, chikungunya, and Zika virus.

Yellow fever probably made its Western Hemisphere debut in the Caribbean in the 17th century. Zika is a more recent import, appearing in Colombia and Brazil in 2015.

Mosquito-borne diseases are nothing new in the tropics, but in late 2015 an unusual birth defect was showing up in unprecedented numbers in the same areas as the Zika outbreak. Infants born with microcephaly are immediately recognizable, with misshapen heads and often brain damage.

Since the association was noticed, it has become increasingly likely that Zika infection during pregnancy can cause microcephaly. We're also learning more about the virus and its transmission; for example, that men can transmit it to women sexually.

But mosquito bites will likely continue to be the main way people become infected. For most people, the infection is either mild or not noticed at all. But the implications for pregnancy are enormous. And Zika is probably heading our way.

Take a look at the map in the New York Times article linked above. Then take a look at these from FiveThirtyEight. The areas most at risk if Zika hits the U.S. have some of the most restrictive abortion laws in the country. Given that Americans are still fighting for basic access to birth control, things are likely to get messy.

I've already seen dozens of patients with questions about Zika virus and travel (I counsel them per CDC recommendations to avoid pregnancy when traveling to affected areas). What happens when it becomes less academic?

Women who contract Zika while pregnant may wish to have abortions. How many would choose this is of course unknown, but we have some serious work to do, and quickly. We need to focus on mosquito control now, as the season is upon us. We need to make sure that women in areas likely to be affected by Zika have information about the disease and access to birth control, and, if desired, abortion.

We like to think that tropical diseases are gone from the U.S., but as West Nile Virus and other outbreaks have taught us, we are 1 shipment of old tires away from an outbreak. We need to prepare for the public health, medical and societal problems that the latest mosquito-borne disease brings with it.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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