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db's Medical Rants



Internal medicine, American health care, and especially medical education



Last Build Date: Sat, 16 Dec 2017 13:04:39 +0000

 



Ward attending notes to my younger self

Sat, 16 Dec 2017 13:04:39 +0000

Finishing my 38th year of internal medicine ward attending, I wish I knew then what I know now.  I estimate the equivalence of at least 10 full years of ward attending, I think this meets the magic 10,000 hour number.  Hopefully, these notes to myself will help some newly minted ward attendings.  The job is […]



The Emperor of Performance has no clothes

Sat, 09 Dec 2017 13:42:47 +0000

Our greatest and worst attribute is seeing and saying that the Emperor has no clothes.  It requires intellectual honesty, a willingness to overcome confirmation bias and perhaps some hubris.  Often we make others uncomfortable with the raw honesty of such proclamations. For years many blogs have decried performance measures.  I have written about this problem […]



On setting achievable goals for behavior change

Sun, 03 Dec 2017 23:58:59 +0000

Long time readers know that I lost approximately 40 pounds in the year starting with Memorial Day 2013.  When I started, I did not have a big goal, rather I had a small goal.  The day I started, my goal was to lose 8 pounds.  After losing 8 pounds, I made a 5 pound goal. […]



May physician targeted performance payment finally receive its death toll

Thu, 30 Nov 2017 15:28:45 +0000

Long time readers of this blog know my disgust with pay for performance.  P4P has many incarnations, all of which are harmful to patients and physicians.  The blogosphere has ranted about this for at least 11 years.  Search P4P on this blog and you will see the vast number of posts regarding this topic. This […]



Thanksgiving Challenge 2017

Sun, 26 Nov 2017 01:58:38 +0000

For many years I set a Thanksgiving Challenge to myself.  The goal was to lose weight between Thanksgiving and New Year’s.  It was a resolution. This year I do not need to lose weight.  So my goal this year is to maintain. My personal plan is to continue working out regularly throughout the month of […]



When to give bicarbonate for metabolic acidosis – increased versus normal gap acidosis

Tue, 21 Nov 2017 17:31:59 +0000

Last week I posted a list of topics that we discussed during a 5 day period of rounding.  I was asked to share my teaching points. We had 2 patients, one who had a normal gap acidosis and one who had an increased anion gap acidosis at admission.  The team did not treat the normal […]



Being a physician – lessons learned from Harry Bosch

Sun, 19 Nov 2017 13:05:03 +0000

I just finished listening to the latest Michael Connelly mystery – Two Kinds of Truth.  His main character in many books is Harry (short for Hieronymus) Bosch.  Bosch is a police detective who epitomizes characteristics that we see in the best clinicians.  Here is a compilation of what I find in this novel as well […]



Things we discussed last week on rounds

Mon, 13 Nov 2017 23:47:12 +0000

Each week on rounds several very interesting topics arise.  In December I plan to discuss these issues on a daily basis, but today I am reflecting on 5 days of ward rounds last week.  I just plan to list some issues, not include the discussions or why we focused on those issues.  Please feel free […]



Tips for IM attendings – Chapter 20 – why we ask questions

Thu, 09 Nov 2017 13:27:47 +0000

I had a wonderful dinner with some medical students last night.  Earlier in the day at morning report I had asked them multiple questions.  Given the ongoing debate over pimping (a debate that will likely never end), I asked them to reflect on the questioning. They had several thoughts (all positive) and during the discussion […]



The neverending IM rounds debate – what is the best style?

Sun, 05 Nov 2017 13:05:47 +0000

I could stop with one sentence – there are several styles that work.  Let me explain. Internal medicine rounds have several goals.  First, we owe our patients the best diagnostic evaluation and then the best care. We owe our patients careful explanations of the day’s plan, and the overall plan.  Too often we have to […]