It used to be that doctors knew best. We told you what to do, and you obediently complied. The world has changed, and the paternalistic system of yore has given way to the shared decision model where patient autonomy is respected. The old way: “Well, I’ll be setting you up for surgery soon.” The new and improved way: “Let’s discuss all of the reasonable options with their respective advantages and drawbacks. Then, ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 22-year-old woman is evaluated for a flare of Crohn disease. A colonoscopy performed 6 months ago showed moderate, patchy, left-sided colitis extending from the descending colon to the splenic flexure. She responded to therapy with prednisone but declined maintenance therapy in advance of conceiving. She is ...

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A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis. It was afternoon, and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made ...

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The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never "crashed."  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 25-year-old man is evaluated in follow-up after recently testing positive for hepatitis B surface antigen. He underwent testing as part of the immigration process from Somalia. Two other siblings also have hepatitis B virus (HBV) infection. On physical examination, he is a young, healthy-appearing man. Vital signs ...

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“In the beginner’s mind there are many possibilities, but in the expert's view, there are few.” Shunryu Suzuki was writing about Zen beginners and masters, but this concept applies to the practice of medicine as well. Experienced physicians are slow to accept a new paradigm, while medical students and new physicians are more open. Sometimes, what we “know” to be true is not. Despite clinical trials to the ...

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According to Hesiod’s version of an ancient Greek legend, because Pandora has opened a jar stuffed full of evil by the Olympian gods, “countless plagues, wander amongst men … earth is full of evils … Diseases come upon men continually by day and by night, bringing mischief to mortals silently.” Curiously that jar was closed before hope was also allowed to escape. Is the legend an expression of how bleak the ...

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There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition. It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications. I see this daily in the office and in the hospital. It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. Of course, every doctor feels that he ...

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There are some questions in health care that can’t be answered with a randomized controlled trial. We can’t randomize babies to inhale secondary tobacco smoke or not to test its health effects. We can’t randomize people to a different number of hours sitting the ER before receiving antibiotics after the decision is made that the patient has a bacterial infection requiring antibiotics. There are some questions where the best available ...

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You’ve probably heard this story before: a young physician, who has spent all of his or her life succeeding and building goals, stumbles into a career without meaning or enthusiasm. Indeed, my story about burnout is much like the rest. Like so many before me, I entered into a career in medicine motivated and eager to change the world through the care of my patients. I grew up in a family ...

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