Who can argue against evidence-based medicine? Who can argue with using evidence to develop guidelines? The key to practicing great medicine must involve using the best evidence to guide our protocols. My son, while in college, was an English major. I remember reading his papers. He often used the phrase “on further reflection.” I often recall that phrase when considering these complex issues. Frederick Nietzsche wrote, “There are not data, only interpretations.” ...

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Now that we no longer have to worry about the SGR, we have a new worry. The law consolidates several measurement tools into one big tool. CMS has declared that it wants to pay for value. The law provides a blueprint for paying for value. The underlying assumption of this approach is that we can define and measure value through measuring quality components. Can we define health care value through measurement? ...

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Many readers know that I favor empiric antibiotic treatment for adolescent/young adult pharyngitis when the clinical signs and symptoms strongly suggest a bacterial infection. I favor narrow target antibiotics and only in the patients with Centor scores of 3 or 4 (and perhaps some 2s when the patient looks very ill). This would exclude over 50 percent of patients from antibiotics. Most organisms already have developed resistance to penicillin, amoxicillin, and ...

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Dr. Wes has written passionately against MOC: ABIM Pleads for Mercy.

But perhaps we should ask first: Why MOC at all? Contrary to years of propaganda promoted through pseudo-science and journal article citations on the ABIM’s website, might MOC have really been created because the ABIM’s consolidated fund balance dropped 43.2% from $54,009,086 on June 30. 2001 to $30,691,329 by June 30, 2013 while the Standard and Poors 500 index increased 37.7% ...

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Maintenance is the process of maintaining or preserving someone or something, or the state of being maintained. Our certification documents that we have trained (in my case in internal medicine) and that we can pass a test on the breadth of internal medicine knowledge. We accept that the ABIM has developed a test the evaluates our entire exposure to the many diseases and treatments that reflect our patients. The idea of maintenance of ...

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All physicians know the scenario. You want to reassure the patient; the patient wants another (usually expensive) test. In our new metric age, we may have a conflict between overuse and patient satisfaction. The article provides some hospitalist data: "Hospitalists know guidelines but overuse tests to reassure selves, patients." How do we balance making our best evidence-based decisions with patient demands? Some experts will tell us that we really have a ...

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During the MOC debate that JAMA sponsored, I was asked what I would do if “I were king” of MOC. As an internist, I believe in first making a diagnosis, then prescribing a treatment. So I have spent time diagnosing my needs as an internist. When I passed my boards I showed knowledge competency. But medicine changes over time. We have major advances and changes since I took my boards. Some examples follow:

Did I tell you that I was a big fan of palliative care? Palliative care started around 15 years ago at the VA where I worked. We saw the service evolve. We saw how the palliative care approach improved the quality of both life and death. Many physicians have not yet accepted or at least understood palliative care. Many physicians use some palliative care principles and believe palliative care is superfluous. ...

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The most valuable lesson about teaching that I ever learned occurred in high school. I took my first algebra test. The questions were easy, and I wrote down the answers. All my answers were correct, but I got a B. After each answer, she wrote “show your work.” She explained that while algebra questions start out easy, they become more complex over time. Only through careful understanding of ones thought ...

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We all want to practice evidence-based medicine.  Yet that phrase is so overused that one must always question the true meaning underlying the use of the phrase. The first assumption that many make is that evidence is a solid structure without nuance.  Yet we can have different experts look at the same evidence and develop different conclusions!  Why else would we have competing guidelines. Consider this quote from Nietzsche: "There are no facts, ...

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