When we think about clinical reasoning, most talks focus on diagnostic errors and the reasons for those errors. The legacy of Kahneman and Tversky focuses on errors and the many named mistakes we make. We focus on avoiding errors, but their work and too often our teaching does not focus on the road to diagnostic excellence. Gary Klein, the pioneer of naturalistic decision making, has focused more on the road to ...

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Coming in to meet the students, house staff, and patients for the first day on service always excites me. This Monday was no exception. What awaited me? How many patients would I need to see? What lessons could I impart? When I arrived, we had 11 patients, two new, and nine had arrived previously. Going through the list, while routine, always stimulated questions and teaching opportunities. Sometimes the team had questions ...

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A wonderful senior resident helped me understand the goal of rounding.  Rounds should focus primarily on understanding the key problems and the diagnostic and therapeutic approaches to those problems.  She suggested that some rounds spend too much time on “minutia” that the resident could handle, and not enough on understanding the big issues.  According to her, rounds work best when we spend our time addressing the problems that the patient ...

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When we studied ward attending rounds, the thought process represented the top attribute that learners valued.  Learners can learn facts from textbooks, but using those facts requires experience and role modeling. I have given many lectures on clinical reasoning, and I have attended many lectures on clinical reasoning.  These lectures can entertain, but one lecture does little to help our colleagues and our learners. We must structure case conferences as a primary ...

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CMS is changing note requirements, among other changes.  Bob Doherty has a wonderful summary: "Medicare's historic proposal to change how it pays physicians." As always, we really will have a difficult time sorting out the unintended consequences of these changes, but they certainly seem like a move in the proper direction.  To me the most important change is a focus on notes: “Allowing medical decision making to be ...

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Learners value efficiency.  As I recall my residency, nothing caused more angst than unnecessarily long rounds.  In the 1970s just like in the 2010s, I had much to do after rounds ended. As an attending physician, my responsibilities involve patient care and aiding learning.  I have always worked hard to do that within a time constraint.  The time constraint requires that rounds run efficiently. Like many things in medicine, efficiency only works ...

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It started slowly.  My former resident and present colleague, Terry Shaneyfelt first authored "Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature." This paper alerted us to the problem.  But guideline fever continued to rage.  Almost every specialty and subspecialty society decided that they needed to join the guideline movement.  They needed to tell us the right way to practice medicine. While ...

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Finishing my 38th year of internal medicine ward attending, I wish I knew then what I know now.  I estimate the equivalence of at least ten full years of ward attending; I think this meets the magic 10,000-hour number.  Hopefully, these notes to myself will help some newly minted ward attendings.  The job is quite difficult and multifaceted.

  • Understand the various responsibilities of the ward attending

Periodically we should reflect on what challenges face patients and physicians.  Over the past few days, I have worked on a list of the issues that concern me the most.  I welcome suggestions for expanding the list. 1. Diagnostic errors. All patient care requires that we make the proper diagnosis.  Too often we make errors.  A recent paper estimated that 30 percent of cellulitis admissions did not have cellulitis.  A similar ...

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In the 70s when I trained, we had no add-on curricula; we had no milestones; we had little interference from governing bodies.  What we did have were role models. In the current century, when I talk with students and residents (and I do that very often) they talk about what they see or do not see from their attending physicians and fellow residents.  The carefully constructed curricula result from excellent intentions, ...

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