FiveThirtyEight had a provocative article: "Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much." The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield competing guidelines. We all know the controversies over breast cancer screening and prostate cancer screening. Recently blood pressure targets and lipid management have ...

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Change causes distress for most people. In medicine we have a hierarchy that disdains most change. Medical students, residents, attending physicians all seemingly reject change. Practicing physicians dislike change. Yet change occurs and is necessary. I learned a great deal about change from my mother. This anecdote may help put change into perspective. Many years ago, we lived in a 3 bedroom house. In the evening we all sat in the ...

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Recently, we had a wonderful reception at the American College of Physician's Internal Medicine 2014. Sitting with leadership colleagues we had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century. Consider the Sippy diet, the Bilroth II, highly selective ...

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Readers know that I went to the University of Virginia as an undergraduate. Since graduating in 1971 I have remained a huge sports fan and academic fan of the university. Those who follow my Twitter account have seen me tweet often about the basketball team. Our coach, Tony Bennett, took his 5 pillars of success from his father, the famous coach Dick Bennett. While these pillars have a Christian origin, I ...

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Over the years I have strived to develop my bedside manner.  On rounds many learners comment on this aspect of my doctoring, and these comments have led to much self reflection.  This commentary may convince some readers that I have the answers, but I do not.  Sometimes I do very well, but sometimes my skills fall short.  I do try to connect with patients and families, and give them confidence, ...

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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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"Old school" is difficult, but doable for teaching attendings.  While prioritization is the key, having a basic framework will help. Here are my personal keys: 1. Sit at the bedside and retake the history of present illness on those patients in whom taking the history is clearly a key.  For example, someone admitted with presumed community acquired pneumonia should have a short history including fever and perhaps night sweats and possible rigors.  ...

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Having now lost more than 30 pounds, I am very close to declaring victory (maybe a few more pounds over the next few months).  A colleague has asked me to write my tips as a handout for patients.  This is a daunting task, but that has never stopped me! The weight loss formula is simple and well known.  Achieving lasting weight loss remains challenging.  The mathematical formula is simple.  Weight loss ...

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As an internist (yes, I am a specialist, just not a subspecialist), I do no procedures.  Patients pay me (albeit mostly indirectly) for my cognitive skills.  But we live in a culture that seemingly rewards procedures more that pure cognition.  Now I understand that procedures are not mindless.  Physicians doing procedures must think prior to the procedure, during the procedure and after the procedure.  But cognition without procedures seems undervalued. The ...

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Since prior to my entrance to medical school, common wisdom for treating sore throats involved the prevention of rheumatic fever.  Since group A strep pharyngitis is the cause of most acute rheumatic fever, all efforts have focused on treating group A strep.   Studies in the 1950s showed that penicillin treatment decreased the probability of patients developing rheumatic fever. The prevailing theory in the 50s and 60s, that we should diagnose group ...

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