Have you ever had a conversation that rattles around in your head for days? Maybe, it changed what you thought you knew about the world.  Perhaps the ideas or comments did not make any sense.  I had a discussion last week and it seemed that logic stood on its head.  The means was defined by the end, with no connection to the beginning, or more exactly, the tail wagged the ...

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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 ...

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In a recent article, Malcolm Gladwell dissected and diagnosed American health care. Throughout our interview, he tackled controversial topics from the Affordable Care Act and medical malpractice to the contrasting Canadian health care system and much more. I expected him to dive deep below the surface and provide new and intriguing perspectives. He didn’t disappoint. But it was his closing comment that caught me off guard. When I asked Gladwell what ...

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With the announcement out of Washington about the 2015 budget, much has been made about the apparent presence of significant support for the development of more primary care practitioners in the years ahead. This support includes programs aimed to encourage medical students and residents to choose primary care as a profession, including loan forgiveness packages. Response in the press has already raised issues with this, suggesting that this move would do little ...

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Imagine -- where would elective surgery be today if patients still worried about operating rooms exploding or developing liver and kidney failure from anesthesia? Having major surgery would be a very different experience without anesthesia.  Before the advent of safe anesthesia techniques, the world of surgery was basically limited to amputations and other attempts at life-saving maneuvers.  Dr. Bigelow's publication describing the safe administration of ether changed everything, and the New ...

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I hear providers groan when we talk about the patient experience and some even tell me that they have no impact on the patient experience, that’s an administration problem. Nothing is further from the truth. If you interact with patients, you influence the patient experience. Some providers think a full waiting room is a measure of patient satisfaction. Actually, it’s a measure of how long patients will tolerate a long waiting ...

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Recently, I attended what may have been my last quarterly medical staff meeting at my local hospital -- ever. (I am retiring from medicine in ten weeks.) I certainly wasn't there for the food, although the fare was much better than the daily servings in the doctors' lounge. Part of the night's agenda was a rousing talk by the hospital's new chief medical officer (CMO). A retired surgeon, the CMO ...

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When I meet a new patient, I’m frequently astounded by the health care he has received. I’ve met patients with absolutely no cardiac symptoms who have been receiving EKGs every six months for years. I’ve had patients brag to me about their annual executive physicals in which myriad tests including treadmill stress tests and chest x-rays were routinely performed. Patients get head-to-toe CT scans under the mistaken hope that they ...

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As an intern in the neonatal intensive-care unit (NICU), I am one of several doctors who rarely see or touch the tiny patients we treat. We sit in a back room off a distant hallway, far removed from the babies, reviewing lab results and blood gases on the computer. Much of the time I feel like the Wizard of Oz, controlling a marvelous machine from behind a curtain. The only uninterrupted ...

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As a psychiatrist, I was trained to begin the mental status examination and overall assessment of my patient as soon as I greeted them in the waiting room. Even now, three decades after finishing medical school, I follow almost the same sequence of actions in my day-to-day interactions with my patients that I did as a resident in training. Granted, there are now electronic medical records and I rarely come ...

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