Donald Ross (an obvious pseudonym) has practiced in a medium sized town for around 20 years.  I count him as a protege as we worked together during his residency.  As a clinician educator, we work with many interns and residents, and sometimes we develop lifelong relationships.  Donald Ross and I share a love of golf, ACC basketball (although we root for rival teams), and internal medicine.  We periodically communicate through ...

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I read and listen to much fiction.  While listening to a fantasy novel, one character verbalizes a most important concept.  Every action has consequences.  Those consequences are both expected and unexpected.  We might predict some unexpected consequences, if we only spend some time to think through the likely impact of that action. Bureaucrats and politicians have imposed a series of administrative burdens on physicians and patients.  We use EHRs that work ...

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Readers are slowly learning about my admiration for the Farnam Street Blog.  The about page describes the blog in this way:

My goal is to help you go to bed each night smarter than when you woke up. I’ll do this by giving you tools, ideas, and frameworks for thinking. I’m not smart enough to figure all of this out myself. I try to master the best of what other ...

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Clinician educators have the opportunity and responsibility to influence students, interns and residents.  While we can have some hubris in our education skills, we must always demonstrate humility in our patient care role modeling. Dr. Orhan Muren, one of my early role models, often told us to never be “cocky” when taking care of patients.  As I recall his admonition, I realize that he was urging us to have true humility. But ...

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During my training in the 70s, heroin use dominated our substance abuse horizon.  We saw many patients with IV drug-related complications.  We saw heroin overdoses. For the next 30+ years, we rarely heard about heroin.  Over the past 10 years we have seen increasing opiate abuse, but the opiates came from prescriptions.  Over the past 2 years, heroin has once again reared its ugly head. This article blames physicians for opiate addiction: ...

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Recently, I spent two days in Greenville, SC as a guest lecturer. During that trip, I had time to chat with some hospitalists. During our conversations, I explored a classic problem: the inpatient-outpatient handoff. Talk with hospitalists and you will discover their angst about getting outpatient information on their admitted patients. Talk with primary care physicians and they echo the angst when seeing recently discharged patients. Personally, I have experienced both sides of ...

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The transition between the basic science years and the clinical years in medical school are jarring, mystifying, exhilarating and thought-provoking. Recently, I did an hour conference with approximately 30 medical students. About half started their clinical year five weeks ago, while the remainder have only three weeks left before they finish the year. They gave me permission to share our discussion. We focused on their (and my) observations about the ...

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Who can argue against evidence-based medicine? Who can argue with using evidence to develop guidelines? The key to practicing great medicine must involve using the best evidence to guide our protocols. My son, while in college, was an English major. I remember reading his papers. He often used the phrase “on further reflection.” I often recall that phrase when considering these complex issues. Frederick Nietzsche wrote, “There are not data, only interpretations.” ...

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Now that we no longer have to worry about the SGR, we have a new worry. The law consolidates several measurement tools into one big tool. CMS has declared that it wants to pay for value. The law provides a blueprint for paying for value. The underlying assumption of this approach is that we can define and measure value through measuring quality components. Can we define health care value through measurement? ...

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Many readers know that I favor empiric antibiotic treatment for adolescent/young adult pharyngitis when the clinical signs and symptoms strongly suggest a bacterial infection. I favor narrow target antibiotics and only in the patients with Centor scores of 3 or 4 (and perhaps some 2s when the patient looks very ill). This would exclude over 50 percent of patients from antibiotics. Most organisms already have developed resistance to penicillin, amoxicillin, and ...

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