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

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Monday, May 25, 2015

That 'old-school' physician that we should all be like

A couple of weeks ago I was on-call and had to go down to the emergency room to see a patient. Before I entered the room, I was told that the patient was accompanied by her long-time physician who was a bit “crazy and old school.” “Hmmm … that's strange … why would her physician be in the room with her?” I thought to myself.

When I went in to introduce myself, sure enough sat next to her was an elderly physician probably in his late 70s or early 80s. After he greeted me with a warm and friendly handshake, he told me that he had practiced medicine in the local area for the last several decades. I still continued to wonder exactly what he was doing there and this thought persisted for the next few minutes. However, as I got further into the interview, I quickly realized just why he was sitting by his patient's side. This doctor had cared for the patient for at least the last 30 years, was in the process of winding down his practice, but felt compelled to come and visit his patient (with no financial incentive to do so) as soon as he heard she was being admitted to the hospital.

The patient, elderly herself and hard of hearing, wasn't able to give me a complete history. But that was okay, because her doctor knew her inside out. Every little detail. When I asked about her medications, he pulled out a notepad and scrolled through it, where he had handwritten all her prescriptions. The relationship between them was obvious, and the respect the patient had for her doctor was also very palpable. After I had got through my interview and examination, explained my findings and treatment strategy (by this time the patient's sister had also arrived), it was approaching 10 p.m. The physician said that he felt more comfortable that his patient was in good hands and left as she was being transferred up to the medical floor.

My interaction with that elderly physician that evening really caused me to reflect on a couple of things. Firstly, the fact that the ER staff and even the physician colleague who had signed the patient over to me thought that the physician was a bit odd for sitting by his patient's side in the ER. How have we got to the stage where a genuine and caring doctor has become the odd one out? Then there's the reality that his generation represents precisely what a personal physician should be. A solid physician with great clinical skills and highly respected by both the patient and their family. Unlike what medicine has become today, this was a doctor who would look you in the eye and think carefully and thoroughly through the diagnosis and treatment plan. It was obvious when he spoke to me that his clinical reasoning skills were top-notch. He wasn't a doctor who was glued to his computer screen, having to spend the majority of his day clicking and typing away—about as far away as possible from the “type and click bot” doctor that is proliferating at today's medical frontlines. The majority of his time was spent in direct patient care and not bogged down by healthcare information technology. Without the aid of a computer, he was able to reel off highly detailed parts of her medical history and previous hospitalizations. He had obviously spent all of his career being his own boss and hadn't been constantly mired in the next administrative battle. This was a doctor who knew his trade and the practice of good medicine.

Sadly, I also realized how this doctor was a dying breed and how much we've lost in our rush to mechanization and consolidation. His solo practice is sure not to be taken over by another similar doctor. But there was also one other recurrent thought that stayed with me for the next few days. I kept thinking about the words that were spoken to me before I entered the room about the “crazy old-school physician.” These words echoed in my mind and I couldn't help conclude that it's actually we (the current generation of physicians) who are the only crazy ones. That old-school physician is exactly who we should all be aspiring to be like.

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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Friday, May 22, 2015

Teaching diagnostic reasoning

Amidoc wrote this comment:

Thank you for sharing this with us.

How about focus on teaching how to avoid clinical errors during medical school and residency? I am sure someone smart can come up with a curriculum and the apply it in real life.

Yesterday I gave Grand Rounds at my alma mater, the Medical College of Virginia in Richmond (sometimes called VCU but I reject the relabeling). The title, “Learning to Think like a Clinician,” is pithy, but may not convey the essence of the talk. In this talk I present patients whose diagnostic process helps us understand the source of diagnostic errors as well as the path to diagnostic excellence. The talk borrows heavily from cognitive psychology and particularly 2 books, “Thinking Fast and Slow,” by Daniel Kahneman and “Sources of Power,” by Gary Klein.

This talk and those books outline a curriculum for understanding the basis of diagnostic reasoning. As noted a physician as Jerome Kassirer, MD, former editor of the New England Journal of Medicine, has called for diagnostic reasoning to be included as a basic science throughout medical school. He and Rich Kopelman started the NEJM Clinical Problem Solving exercises (another great way to learn medicine and the diagnostic process).

But I would argue that writing a curriculum is not the answer. The answer must come from improved clinician educators. We assume that anyone who finishes a residency and/or fellowship can teach medical students and residents. But skilled medical education requires specific skills. One skill that some cannot master is the skill of making explicit ones thought processes. Our research on ward attending rounds, and my anecdotal experience in talking with many students and residents, teaches us that learners want to understand how the process works. So we need to trainer the educators on how to teach medicine. We should develop more rigorous training for medical educators so that they can help their learners grow into great diagnosticians.

Unfortunately, we who value the art of diagnosis are handicapped because diagnostic excellence is difficult to document with measures. We cannot measure diagnostic error rates, because diagnoses are often difficult and gold standards are difficult to determine.

But we do have a responsibility to try. We should value diagnostic reasoning more as our learners know that they need to learn these skills.

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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Thursday, May 21, 2015

Punished for precision (or, too much information from the micro lab!)

We recently had a patient's blood culture turn positive for a Gram-positive, catalase-positive, facultative diphtheroid. In the “pre-matrix-assisted laser desorption/ionization (MALDI)” era, we'd have called this isolate a “diphtheroid.” Taking into account other aspects of the case, the National Healthcare Safety Network (NHSN) definition would have categorized this as a contaminant (diphtheroids being on the “common commensal” list maintained by NHSN). By virtue of the wonders of mass spectrometry, we are now able to identify the organism to species-level as Actinomyces neuii, an organism previously categorized as CDC group 1-like coryneform bacteria (also on the “common commensal” list).

A. neuii isn't anywhere on the NHSN organism lists. However, Actinomyces species (as a group) can be found on the “all organisms” list but NOT on the “common commensal” list. The NHSN rules tell us we have to categorize any organism on the “all organisms” list that isn't also on the “common commensals” list as a pathogen, meaning this positive blood culture now helps define a central-line associated bloodstream infection (CLABSI).

And that's the story of how a contaminated blood culture became a CLABSI. We've had other similar cases since we introduced MALDI-time of flight (TOF). Before the CLABSI rate became worth millions of dollars to a hospital's bottom line and reputation, this might have been easy to navigate. Now, though, it's a much bigger deal.

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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Wednesday, May 20, 2015

Pneumonia prevention bundle in nursing homes: a cluster-randomized trial

If you're looking for another infection prevention bundle in long-term care, look no further than the March 15 issue of Clinical Infectious Diseases that included a cluster-randomized trial of a pneumonia prevention bundle in 36 Connecticut nursing homes by Juthani-Mehta and colleagues at Yale (full text free). Residents in the intervention nursing homes with at least 1 risk factor (impaired oral hygiene or swallowing difficulty) received a bundle that included manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding.

The primary outcome was development of first pneumonia defined as “presence of (1) a compatible infiltrate on chest radiograph (CXR) (if previous CXR was available, the infiltrate had to be new or worsened) and (2) at least 2 of the following clinical features within 72 hours of the CXR-documented infiltrate: fever, pleuritic chest pain, respiratory rate over 25 breaths/minute, worsening functional status (ie, decline in level of consciousness or activities of daily living), or new or increased cough, sputum production, shortness of breath, or chest examination findings.” The secondary outcome was first lower respiratory tract infection (LRTI).

After enrolling 834 participants (434 to the intervention arm and 400 to the control arm), the data safety monitoring board terminated the study for futility. Results showed no significant differences for cumulative incidence of first pneumonia or first LRTI between intervention and control arms. In fact, you can see in the study that that the intervention arm appears to have higher incidence of first pneumonia, which is concerning.

Of note, adherence was 87.9% to chlorhexidine, 75% to toothpaste and 100% for upright feeding position in the intervention facilities. The authors offer several explanations for the study's failure, none of which are entirely convincing. For example, adherence at these levels should have still shown some benefit and not a trend toward harm, so it's unlikely that compliance explains the results. For those interested in reading more, there is an excellent commentary by Lona Mody. Congratulations to the authors and journal for publishing this important negative study.

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Friday, May 15, 2015

Learning from the detectives

Many readers know that I love mystery novels and TV shows. Recently I was talking with a third-year student, and realized that one of the reasons I love internal medicine is that every day I am a detective. As I watch detective shows and movies and as I read or listen to detective novels I am learning lessons about being a better diagnostician.

The best detectives collect data prior to coming to conclusions. They avoid premature closure. As they look at the evidence they do not act on the obvious, but rather ask about missing data. They refuse to rush to judgment.

The best detectives interview “persons of interest” during their investigation, but when they find more evidence (using from the CSI group) they resume their interviews, asking new questions, building on the scientific evidence.

The best detectives use mind play to consider possibilities. They tell a story (either out loud, or in their minds) and in the telling test that story for inconsistent data.

The best detectives obsess, not willing to give up on finding the answer. They keep searching until the answer becomes crystal clear.

Could you substitute “the best internists” in the above paragraphs?

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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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.

Auscultation
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 Richmond, Va., 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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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