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 ...

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On November 1973, I had an epiphany.  My first week on my internal medicine clerkship, I realized that I had found my specialty: internal medicine. Prior to medical school, I had worked with emotionally disturbed children in an inpatient hospital.  I really enjoyed the experience, and learned a great deal.  During my first two miserable years in medical school (I disliked how they taught the basic sciences and even more how ...

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Over the past two days, listening to separate podcasts, I have heard the same story and now have a better understanding of artificial intelligence. A Freakonomics podcast — The Future (Probably) Isn’t as Scary as You Think:

And in general, what’s happened in the past couple of years is the best chess player on this planet is not an AI. And it’s not a human. It’s the team that ...

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Spend time talking with non-medical friends and acquaintances. Ask them about their medical experiences. Imagine what they want, or ask them what they want. People want to feel that their physician has spent adequate time talking, examining and explaining. They want to look into the physician’s eyes. They want the best possible care, but caring matters. Our “system” discourages such care implicitly. Physicians do not get paid to spend time with patients. ...

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A friend asked me recently about statins. He takes a statin for primary prevention but is concerned that he has muscle pain and weakness as a side effect. So he posed the question: “How important is the statin?” The Washington Post had this recent article: "Who should take statins? A vicious debate over cholesterol drugs."

But while nearly all experts agree that statins are beneficial for people at a substantial ...

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The art of eliciting the medical history requires medical knowledge, cultural knowledge, and many “people skills.”  History taking is not science, but rather, art, because it requires interpretation and clarification.  Patients with the same symptoms express them differently.  A major feature of the art of medicine involves learning how to interpret different descriptions of the same phenomenon. A few examples might clarify these concepts. The patient tells you that they have chest ...

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Around 30 years ago, LRZ taught me a most important lesson.  LRZ, one of my most fondly remembered patients, was a classic blue collar guy.  He had a wonderful, gregarious personality.  He had significant systolic dysfunction, yet still worked hard for the city.  Amongst other things he did, he shoveled the salt into trucks on snow and ice days.  He functioned well most days. One day he came to see me. ...

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The term, "evidence-based medicine" (EBM), provokes strong feelings from its proponents and its skeptics.  I spent a full day recently in discussions about EBM.  As the day proceeded I understood that evidence is wonderful when it fits the clinical question, but that too often the clinical question does not, and probably will not have adequate evidence. We have great evidence for some clinical questions.  We all know that ACE inhibitors decrease ...

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Charles Bukowski once said, “Wherever the crowd goes, run in the other direction. They’re always wrong.” How does one become a master?  What process do we use to have the highest probability of success? Here are some examples. "Picasso was an extraordinary craftsman, even when measured against the old masters. That he chose to struggle to overcome his visual heritage in order to find a language more responsive to the modern world ...

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