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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