Blaming the American Medical Association’s Relative Value Scale Update Committee (RUC) for everything has become the latest fashion. The RUC is causing climate change. The entire health care cost problem comes from RUC decisions. Alex Rodriguez took performance enhancing drugs because of the RUC. But the RUC did not create the system. They try hard to balance a system that is designed to achieve the wrong outcomes. The RUC has become ...

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A few weeks ago I was an expert witness in a malpractice trial. In this post I will use generalities and specifically not reveal any details of the patient or the court case. I first became involved in this process several years ago. My involvement included a deposition, reviewing medical records, reviewing other expert depositions, discussing the patient’s most unfortunate story with lawyers for two different defendants, and finally testifying. ...

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You have to love the blogosphere.  The latest big issue concerns lower ABIM pass rates.  Here are a series of blog posts worth considering. Dumber Doctors?

One concern that has a ring of truth to it is that young doctors have become great “looker-uppers,” and have lost the sense of what it’s like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, ...

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I had a nice conversation with a dermatologist at a party recently.  He started complaining about the notes he receives from other physicians.  He used terms like piles and piles of junk. Talk to any experienced physician and they will tell you that once upon a time our teachers taught us to write notes appropriate to the situation, not appropriate to the billing system. Several years ago I ranted about the necessity ...

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I recently tweeted about Danielle Ofri’s important piece, The Doctor Will See Your Electronic Medical Record Now.  I like the piece, and especially like some of the quotes, but still I believe the problem needs an expanded take. Context represents the major advantage of 38 years experience as a physician.  Over time, one sees trends come and go.  Hopefully one can see the strengths of the “good old days” and ...

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Attending physicians have great responsibility. We have ultimate responsibility for patient care and for medical education. Medical education involves sharing facts, the thought process and bedside manner. Recently we had a “frequent flyer” admission. For a few years, the housestaff labelled this patient as non-compliant – and even wrote it in his chart. He is young (less than 30) and has a chronic disease. He had multiple admissions and often left ...

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The Wall Street Journal has a question that I cannot really answer in their article, Nurse Practitioners and Primary Care. This question has an implicit assumption that primary care is one thing, and that that thing is relatively straightforward and simple. I have written about this problem incessantly for the past 11 years on this blog. The term primary care has become the equivalent of a Rorshach test. When we ...

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I still think that the third year of medical school serves a wonderful purpose. I never learned more during my entire school experience (perhaps I learned more as an intern, but that is post-graduate). Danielle Ofri writes through darkened lenses: The Darkest Year of Medical School. So for the non-physician readers let me give my opinions on the third year of medical school. After two years of mostly classroom experiences, our ...

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Once upon a time (actually when I did my residency), we worked long hours, were taught well and learned from our patients. Residency training had minimal rules. When we looked for a residency we took work load into consideration. Some residencies were more challenging than others. I choose a busy residency because I thought (back then) that I needed to see sufficient numbers of patients to become a good internist. Our ...

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Why do we never consider unintended consequences? Whether we are thinking of legislation or physician led guideline panels, or governing bodies (like ACGME), the lack of consideration of unintended consequences remains mind numbing. Let me provide some examples. Please read this articles about how the war on drugs has fueled the hepatitis C epidemic. One could also argue that this war damages more young people than the drugs themselves. Many illicit ...

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