In trying to understand my own burnout, "control" (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I'm unearthing bones not already thoroughly analyzed. But I can give instructive personal examples. For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During ...

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In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting.  Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan.  Fear of missing something pervades every emergency department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures. Of course, the driving causes of increased testing ...

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Cardiologists are causing patients to get cancer. It’s true. Cardiologists routinely perform angiograms on patients who have no heart disease whatsoever. As shown in this Harvard newsletter, each angiogram exposes the patients to about 7 mSv of radiation. Add in the myocardial perfusion imaging at another 25 mSv of radiation and you have enough radiation to cause cancer in an otherwise healthy individual. And cardiologists routinely subject patients with normal coronary arteries ...

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Would you tell me, please, which way I ought to go from here? That depends a good deal on where you want to get to. I don't much care where – Then it doesn't matter which way you go. - Lewis Carroll In the new world, payers will increasingly ask before reimbursing medical imaging: why did you bother finding out? This is why we must pay attention to clinical trials. An instructive case is in the ...

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When you get frustrated with my interpreting a chest x-ray as “atelectasis at the right lung base, pneumonia can't be excluded,” trust me, I don’t enjoy it. But when you ask me to rule out pneumonia you leave me no choice but to tell you that pneumonia can’t be ruled out. To rule out a disease a test must have a sensitivity of 100%, meaning there should be no false negatives. ...

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Nothing puts more fear into the heart of an internist than a dermatologic chief complaint. And for good reason: we have very little exposure to the breadth of the field. To us, all rashes seem to be maculopapular, all bumps are pustules … or was that nodules? It’s not that we internists don’t care about the skin or don’t appreciate its complexity. Rather, we simply haven’t seen enough bumps, rashes, and ...

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Recently, I spoke with a primary care physician (PCP) about a young runner who had a syncopal episode. Because of the increasing awareness of sudden cardiac death in athletes, she had an electrocardiogram and an echocardiogram to look for structural abnormalities of the heart. The PCP was inclined to dismiss the syncope as an isolated episode. However, the echocardiogram, otherwise normal, equivocated: “possible hypertrabeculation of the left ventricular apex, consider cardiac ...

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I hear it over and over again. From a nurse, “She can’t have providine prep, she has a shellfish allergy.” From the patient, “I can’t have the contrast because I’m allergic to iodine and shellfish.” The list of allergies placed in the chart by a doctor, “Radiocontrast. Iodine. Shellfish.” It’s not the fault of the patients who are typically repeating the medical misinformation they have been given. However, the medical professionals who perpetuate the ...

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You know that old joke. What's a radiologist's favorite plant? The hedge. Radiologists are famous for equivocating, or hedging. "Pneumonia can't be excluded, clinically correlate," or "probably a nutrient canal but a fracture can't be excluded with absolute certainty, correlate with point tenderness." Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice ...

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asco-logoOrdering CT, MRI, or PET scans for my patients when they feel well always makes me nervous. As a radiation oncologist, I’ve chosen to frequently make observations that potentially find active, progressive cancer. And this creates an existential crisis that scares me -- but not as much as it scares my patients. With each test, I set in to motion a real-life application ...

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