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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I have spent three days at the Society to Improve Diagnosis in Medicine. Whenever I come to this meeting, I have insights from listening to talks and many conversations with leaders in the field. When one considers diagnostic errors, one must consider two important factors: physician factors and system factors. We have a major system factor that can cause problems. Most hospitals in the U.S. require a diagnosis for admission. I ...

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When asked to describe my career, I consider myself primarily a clinician educator.  Recently I have reflected on the influences that allowed me to have a successful career doing what I love.  This post is not meant to mention all those influencers, but just some that I recall often.  As I have thought about this post, I quickly realized that all the “heroes” that I recall focused on clinical education. ...

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According to Wikipedia, "Productivity describes various measures of the efficiency of production. A productivity measure is expressed as the ratio of output to inputs used in a production process, i.e., output per unit of input. Productivity is a crucial factor in production performance of firms and nations." Please tell me how this relates to being a physician or a patient.  We do not produce anything.  Rather we work with individuals to ...

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Ratings have become a national obsession.  U.S. News & World Report rates colleges, medical schools, hospitals, subspecialties, etc.  Some private firms develop physician ratings.  Many insurance companies provide physician report cards.  Intuitively most physicians understand that these ratings have serious flaws, yet they persist. Here's a quote from a Malcolm Gladwell article that I had read and forgotten: "The Order of Things: What college rankings really tell us":

A ranking ...

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The Society to Improve Diagnosis in Medicine has on its website this quote:

  • 1 in 10 diagnoses are incorrect.
  • Diagnostic error accounts for 40,000-80,000 U.S. deaths annually -- somewhere between breast cancer and diabetes.
  • Chances are, we will all experience diagnostic error in our lifetime.
The current focus on diagnostic error raises an interesting question:  Is this a larger problem in 2017 than in the 1970s and 1980s? In this post, I ...

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Antibiotics save lives, but antibiotics can have negative effects.  When patients have bacterial infections, we want to treat them to prevent complications of the bacterial infection, but not treat them for an excessive duration.  So we have a Goldilocks problem -- we want antibiotic duration to be just right -- neither too short or too long. Some clinical conditions have adequate research to define the Goldilocks duration.  Community acquired pneumonia only ...

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Over the past decade, I have thought often about the benefits and the problems of clinical guidelines. The first concept that attracted my attention was reading about conflicting guidelines.  Given the same data, different guideline committees would have significantly different recommendations.  At the least, this problem raises questions about guideline validity.  It makes clear that committee perspective could influence recommendations.  Guideline recommendations sometimes are clear and demonstrably evidence based, but too ...

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1973, as we prepare to start our clinical rotations, the chief medical residents taught us the new concept of SOAP notes. Larry Weed developed the concepts of the problem-oriented medical record and notes that included subjective, objective, assessment and plans for each problem.  We wrote our notes each day using his system. I have wondered in many conversations what he would think of the unreadable computer printout notes of ...

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When we walked into the room, you could sense the anger and frustration on the patient’s face, as well as two other relatives in the room. We knew that the patient had had lung cancer for several months and had failed radiation and chemotherapy. He had labored breathing and looked miserable. I went to his bed and asked if I could sit down on his bed. I took his wrist and began ...

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Longtime readers know of my fascination with the affect heuristic. Simply stated, we overvalue the benefits of a concept that we like, and underestimate the problems or vice versa. This article about direct primary care induces conflicting analyses: "Here is the PCP crisis solution, and it’s simple." I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. ...

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