Some thoughts on diagnostic reasoning


Category : Medical Rants

Yesterday I tweeted about our success in making some worthwhile diagnoses in the category of unusual presentations of common diseases. As I consider these successes, the principles of diagnostic aggressiveness become central to my thoughts.

For arguments sake let’s imagine three types of diagnostic reasoning. The first occurs when there is no diagnosis but we know something is wrong. These patients generally require a broad differential and much clinical thought. We often go back and collect more history, repeat the physical exam and think broadly about labs and imaging. We often need several consultants and often biopsies.

The second version includes the majority of patients – a straightforward diagnosis. We need not spend much time on diagnosis unless the respond to treatment raises warnings that we might have the wrong diagnosis.

The third version involves patients whose presentation involves some subtleties. These are the patients who too often do not stimulate diagnostic curiosity. Yet

, when we pay attention to the subtle clues, we often reopen the diagnostic process. The most fulfilling diagnoses that I and my teams have made occur in this latter category.

This fits an Osler quote, “The value of experience is not in seeing much, but in seeing wisely.” The astute diagnostician observes a lab, or physical finding, or imaging finding that does not fit the assumed diagnosis, and has courage to question that diagnosis. Sometimes the trigger finding does not yield a new diagnosis, but we still have the responsibility to wonder

, think, and pursue another diagnostic possibility.

We have presented 2 such cases in our @unremarkablelab YouTube videos: and a presentation that should be added to the web site tomorrow –

Speeding vaccination – a supply chain problem


Category : Medical Rants

Many critics have emerged on COVID19 vaccination speed.  News channels have interviewed experts who seem confused as to why we are giving vaccines so slowly.  They should read the work of Eliyahu Goldratt who championed the Theory of Constraints.  His books could certainly help policy makers look at vaccination queues in a very different way.

In his novel

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, The Goal, he wrote:

… the professor discloses the Theory of Constraints: “A bottleneck is any resource whose capacity is equal to or less than the demand placed upon it. A non-bottleneck is any resource whose capacity is greater than the demand placed on it.” Jonah carefully explains that Alex must NOT try to balance capacity with demand, but instead balance the flow of product through the plant. 

Our current capacity for delivering vaccines does not meet the demand.  Thus, we have a clear bottleneck.  What makes this even more complex is that we currently have multiple bottlenecks in vaccine distribution.  Unfortunately, each state develops its own bottlenecks.  In my state, the Department of Public Health has written this policy:

Beginning the week of December 28, residents and employees of Long-Term Care facilities began receiving vaccination through the federal Pharmacy Partnership.  Once persons in Phase 1a have been offered the vaccine, Alabama will move into Phase 1b.

This policy has developed a bottleneck.  We are waiting for everyone in Phase 1a to have vaccination offered before moving to the next tier.  This strategy

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, based on CDC recommendations, slows down the vaccination process.  Other states have similar bottlenecks.

Here is the key question: How does one protect Tier 1a candidates and yet use all the available vaccines?  One possibility is through staggered scheduling.  Each site determines how many vaccines they can deliver each day.  Now this number will be an estimate given that some 5 dose vials actually have 6 (or even 7) doses.  We have learned that many vials contain enough extra volume to get 1 or 2 extra doses from the vial.

Let’s assume 50 available vaccines for next Thursday.  Today is Friday and the schedule opens for all Tier 1a candidates.  They are notified that they need to make their appointment by Tuesday.  If Tuesday comes and there are any unclaimed slots, those slots will become available to Tier 1b candidates.  Finally, on Wednesday the site opens a “last minute” list.  This list would be for anyone in Tier 1a or 1b who is willing to come either a scheduled person misses or cancels their appointment or extra doses (from vials) become available.

In this scenario, the vaccination site would deliver all the available doses for that day.  Unfortunately, we have read reports of some sites having to discard doses at the end of the day. With appointments we also diminish the risk of a super spreader event from too many people waiting in line for long periods of time.

Given such a system, we would then potentially develop a second bottleneck – vaccine supply.  The solution to vaccine supply problems is more complex but represents the problem we can more easily accept.

We have a responsibility to vaccinate as many people as we can as quickly as we can.  Priority lists are useful, but they should not slow the vaccination process.  Tier 1a candidates should always carry a priority.  Unfortunately, many Tier 1a candidates have had the opportunity to receive the vaccine but have declined.  When they change their mind, they can make an appointment in this system. 

Once we see significantly decreasing need for Tier 1a, we open up Tier 1b for advanced appointments and let Tier 1c make the later appointments and register for the “last minute” list.

Achieving “warp speed” in vaccine delivery requires a flexible system that both respects each Tier but does not delay vaccines for the next Tier when the higher priority Tier is not using all the potential slots.  We need to remove the artificial constraints to achieving a highly efficient supply chain.  We have enough demand; we must match the supply to the demand as reasonably as possible.

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Lessons from Range by David Epstein


Category : Medical Rants

I received an email from Ryan Holiday – author of The Obstacle is the Way, a wonderful book that introduced me to Stoic philosophy as a guiding principle. In that email, he recommended Range: Why Generalists Triumph in a Specialized World by David Epstein. As a generalist, the title intrigued me. So as I am prone to do, I bought the Audible version, and over a 10 day period, listened to the book.

Like many books in this genre, one can criticize the trees of his argument, but I think he gets the forest right. This website has a collection of reviews, many of which are somewhat critical. Nonetheless

, I found that his stories helped me understand much of my personal success and happiness with my career.

The book has several major points. He makes a reasoned argument that for complex careers (be it sports

, arts, business or medicine) one benefits from starting with breadth. Unless one is working towards expertise in a “kind problem” (examples, chess and golf), then a variety of experiences allows one to discover where they want to specialize. Often early specialization fails because as we grow, we too often find that the early specialization ignores the most important success attribute – finding ones passion.

As I think of my career, I “flirted” with many majors in college prior to settling on psychology. Then for the first 2.5 years of medical school I again dated several specialties. After a week on the internal medicine rotation, I knew that I had found my home, my passion and my career.

Yet once I chose internal medicine

, I once again considered a variety of subspecialties. I even did a year of basic science nephrology fellowship, and had the courage to quit, as I missed patient care and teaching too much. The research did not give me the same satisfaction.

Epstein devotes significant time in the book to the value of leaving certain situations. I left a fellowship and joined a new division of general internal medicine. Originally

, I had considered finishing a clinical fellowship, but GIM grabbed me as a great choice. I actually like most subspecialties in internal medicine. The complexity of managing multiple problems satisfies my love of puzzle solving and mystery novels.

Epstein worries that overspecialization makes it more difficult to solve many complex problems. He argues that breadth of background allows us to make intellectual connections that overspecialization makes less likely.

Now I must admit that the idea of this book and the many examples likely appeals to me because of confirmation bias. One look at my CV shows that I do have some recurring themes, but also a great variety of articles. Many articles started with thinking about a problem in a different way thanks to varied experiences.

He is a storyteller. I suspect he has found stories that fit his general hypothesis, but since I like his hypothesis, it does not bother me.

Regardless, this book will stimulate your thoughts about expertise, the advantages of generalization and the advantages of specialization. As a clinician-educator, reading books like this eventually help me and give me insights into the education process. Perhaps that is the most important message of the book. We should not restrict our learning to our specialty. We should learn from other fields. This book makes my top list of non-medical books for junior academicians.

For those interested:

  1. Made to Stick – Chip and Dan Heath
  2. First, Break All the Rules -Marcus Buckingham
  3. 7 Habits of Highly Effective People – Stephen Covey
  4. The Elements of Style – Stunk & White
  5. Drive – Daniel Pink
  6. The Obstacle is the Way – Ryan Holiday
  7. The Tipping Point – Malcolm Gladwell
  8. Sources of Power – Gary Klein
  9. Originals – Adam Grant
  10. Thinking, Fast and Slow – Daniel Kahneman
  11. Range – David Epstein

Internal Medicine is a Wicked Problem – implications


Category : Medical Rants

Currently listening to RANGE: Why Generalists Triumph in a Specialized World by David Epstein. In the first chapter he discusses the differences between wicked problems and kind problems. For example, chess is a kind problem. It has specified rules and clear outcomes. Because it is a kind problem

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, AI can successfully play the game.

Wicked problems do not have rules or even a single known solution. One cannot always determine outcomes because we have many variables and many dimensions to the outcomes. Internists face wicked problems regularly. Many of us chose internal medicine because we love the challenge of these wicked problems.

Diagnosis is a classic wicked problem. We deal with a large variety of inputs and are not restricted to one clear answer. Some patients have more than one diagnosis explaining their symptoms.

Often performance measures, experts and guidelines treat testing or management decisions as if they were kind problems. But clinicians quickly understand that each decision has nuances based upon the patient’s complexity. Even Evidence Based Medicine can suffer because the evidence base does not really fit the patient we are considering.

And that is the problem we confront. We want to measure quality

, yet we are facing a wicked game. With some literary stretching, consider that once famous song “Wicked Game” by Chris Isaak – “What a wicked game you played to make me feel this way”. While he is talking about love, I will take the leap to say that trying to measure quality is actually a wicked game. We have too many variables for which we cannot account.

We can measure the kind (or tame) problems in medicine – central line infections, incorrect medications delivered to patients, wrong site surgery, etc. But what should we do with measures that we try to apply to complex patients.

We would love to measure diagnostic error, but no one has yet solved this wicked problem – and I suspect there is no solution

, because diagnosis is so complex process. We rarely have a gold standard diagnosis. Sometimes we cannot make a diagnosis at the initial presentation. At what point do we declare a diagnostic error?

I would love your thoughts on the wicked problem concept. We are using kind problem tools to solve wicked problems. This will often not work and create frustration. We therefore have measures that can drive the wrong care.

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40 years of ward attending


Category : Medical Rants

January 1, 1980 I walked onto the 7th floor of the old North Hospital at the Medical College of Virginia to make rounds as the attending physician. I had spent much time there as an intern and resident, but now I had a new role.

As I reflect on 40 years and probably between 12 and 15 years of total time making rounds, I first feel fortunate that I quickly discovered that my vocation was also my avocation. Now while I have retired from administrative responsibilities, I still devote 3.5 months each year to rounding with students, interns and residents. And each rotation still brings out the same excitement of going to the bedside and trying to help patients, of exposing students to the wonder of internal medicine, of helping interns through that difficult year and of helping residents in the final year of their internal medicine journey.

When I started, I thought that I really knew what I was doing. On reflection, I had some excellent instincts, adequate knowledge and yet much to learn about leading a ward team. The job has changed dramatically over these 40 years, and hopefully so have I.

In 1990, I had the wonderful opportunity to spend a month at Stanford, learning about teaching from Dr. Kelley Skeff. To this day, he remains one of my heroes and important colleagues. He taught us how to evaluate our own teaching. He provided a structure of the attributes for successful teachers:

  1. Creating a Positive Learning Climate
  2. Organizing Control of the Teaching Session
  3. Communication of Educational Goals
  4. Promoting Understanding and Retention
  5. Evaluation of the Learner
  6. Providing Feedback
  7. Fostering Self-Directed Learning

To read more from Dr. Skeff

His insights and videos allowed us self-reflection. Under his guidance, we learned to strive for improvement and to critically evaluate our own teaching. I borrowed much from Kelley.

He transformed my teaching in many ways. The most important in reflection was that I began seeking ways to assess my own teaching through student

, intern and resident feedback. I learned that experimentation was desirable for teachers – as long as one could adequately evaluate the experiment. Over the years my teaching has matured thanks to the patients, students and housestaff who have given me either direct or indirect feedback.

Teaching attending responsibilities have changed dramatically over the years. When I started we never wrote notes. Then we transitioned to brief notes for billing.

It took many years to developed my unique ward rounds teaching style. I am happy to argue that there is no correct teaching style

, rather each attending physician needs to develop a style that works for patients, students and housestaff.

Medicine has changed dramatically over the past 40 years. We treated heart failure with digoxin and furosemide when I started. We had no HIV reported, no MRSA, nascent CT scanning and MRI, many fewer drug classes, and no billing requirements. Our understanding of pathophysiology has grown. Our ability to diagnose prior to autopsy is much greater, yet we likely make as many diagnostic errors now as we did then.

The research into what makes successful ward attending rounds – Using cognitive mapping to define key domains for successful attending rounds – further helped me understand what to emphasize and what to de-emphasize.

At the beginning I aspired to become a great clinician-educator although no one used that term. In the 70s and 80s (and for some today) most deans and chairs assumed that any good physician could teach clinical medicine. Today we are more clearly defining the value of great clinician-educators and hopefully insisting on quality (although this might be an aspirational hope).

So what do I know now that I did not know then. First, I have a much better personal understanding of my limitations. I know when to ask for help. Second, I have developed my best style. I allows start in the team room, discussing each patient, having the team tell me their plans. We often have a brief educational discussion of some aspect of the patient (dx, rx or something tangential). Once we all understand the general plan for the day, we go visit each patient. At the bedside I often am the “role model”. I repeat parts of the history when appropriate, repeat the high yield physical exam, answer patient questions, and make certain that the patient understands the day’s plan. I deliver bad news if necessary. Afterwards, we often debrief the team about bedside manner. Whenever we have images to view, we walk to the radiologists. I started doing this several years ago, and it has become extremely popular with the housestaff and students. It also helps us more quickly get to the proper diagnosis.

My advice to junior attendings:

  1. Read both linked articles
  2. Try hard not to micromanage
  3. When you disagree with the team, or when you are directing the plan – make your thought processes explicit – that is the number one wish of your learners
  4. Respect their time – always finish on time , even if you must see a few patients w/o the team
  5. Get to know the team members
  6. Ask team members what they did for fun on their off day
  7. Give feedback daily – both positive and formative – and label it as feedback
  8. Touch patients, sit down, learn who the patients are – your learners will emulate your bedside manner , so make it impeccable

I have left much out. Being an internal medicine ward attending is and has been my perfect vocation and avocation. I hope they let me reach 50 years.

Thanks to the many patients, students, interns and residents who have challenged me to be a better physician and a better educator. You have given me the great gift anyone could receive.

And on February 16th I go back on service for another 1/2 month. Looking forward to it.

Help your future colleagues


Category : Medical Rants

As a ward attending physicians, we have a great opportunity and responsibility. We are helping patients and helping our future colleagues grow into the physicians that patients need.

Ward rounds are never about making the attending physician’s ego grow. They are always about patients and learners.

We must embrace servant leadership as a way to lead rounds. I have written about this concept for many years. These old posts are (IMO) worth rereading.

And this one

The problem is persistent. We have too many leaders and ward attending physicians who feed their ego through intimidation. We need leaders (and remember all ward attending physicians are in leadership positions) who serve their profession. What we do is too important too not fulfill the words in the Hippocratic Oath.

To consider dear to me

, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

The danger of assuming


Category : Medical Rants

Recently I have spent much time listening to linguistic podcasts. They have triggered many thoughts about how we take histories from patients. Linguistics represents a very complex science of language.

One concept that has intrigued me involves the meaning of words. When we hear words or read words, we automatically assign a meaning to those words. Too often, especially when we are students and residents, we make assumptions about meaning. However, with experience we learn that words mean different things to different persons.

Experience teaches us that certain words have different meanings amongst patients. Thus, we have to practice our questioning skills to determine the story with precision. Some examples that come to mind include: diarrhea, pain, weakness, shortness of breath and dizziness. Patients often use these words to describe their symptoms

, but further questions reveal a wide variance in their meaning of the words.

For example

, when a patient claims diarrhea, we should not start ordering tests without further characterizing the symptoms.

Learn to not make assumptions from the words patients use without spending the time to further specify the symptoms. Assuming definitions without clarification will often lead to over-testing or misdiagnoses. While it takes precious time, we have a responsibility to understand what is bothering the patient. We should not assume that we know just from single word complaints.

On Casuistry, Guidelines and Performance Measures


Category : Medical Rants

Malcolm Gladwell’s wonderful podcast – Revisionist History – has just focused 3 episodes on the Jesuits and their use of casuistry. I was not familiar with the term, so here is one definition –

Casuistry is – a resolving of specific cases of conscience, duty, or conduct through interpretation of ethical principles or religious doctrine.

As I listened to these episodes, of course I pondered what this means for medicine. Perhaps I have massaged the idea beyond recognition

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, but the podcasts did stimulate these thoughts.

The intent of guidelines (at least I think) is to provide a general approach to a medical situation. General approaches have great use, but they do not address the particulars. The excellent physician should have an understanding of the particulars. The particulars are the context of the patient, their social determinants, their other diseases, their health care desires, etc.

As insurers and administrators try to use performance measures to evaluate physicians, they miss the particulars. We care for patients with diabetes or coronary artery disease or no obvious disease. We do not care fo a blood glucose or a lipid level or a blood pressure. We have a moral and ethical responsibility to help the patient make the best decisions about their health care now and in the future.

The idea behind guidelines and performance measures makes assumptions that ignore the particulars. We cannot assess a physician with simple measures, because our patients are not simple. We do not treat a simple mechanical construct, rather we interact with complex organic patients.

Used properly, guidelines can help us understand the evidence for testing or treating a particular situation, but they should not dictate our course of action. We must consider each patient’s particulars.

Such a course leads to inconsistencies. We always have difficulty determining whether a patient has received the best treatment. The details (particulars) often drive us to treat the exact same situation differently in different patients.

I think we have a responsibility to our patients to develop the wisdom to give them highly individualized care. Measuring that care is complex. Some measures can help guide us

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, but we should use them carefully. Assuming that adherence to measures developed by well meaning committees defines good physicians seems to over simplify the physician’s role.

As Einstein did not say – Not Everything that Counts can be Counted.

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Thoughts after a year of podcasting


Category : Medical Rants

Twelve months of podcasts – 2 per month – are now available at Annals on Call. During those 12 months, I have learned a lot from my guests and learned a great deal about podcasting and interviewing.

Many have asked me to tell them the story of the podcast – how did it come bout? how long does it take to podcast? how do I pick guests and topic? So here is my story.

A couple of years ago Dr. Christine Laine, the excellent editor of the Annals of Internal Medicine, asked me if I would do something “social media” for the Annals. We talked about blogs and podcasts. For the next year, we decided to design a podcast.

Over the past 4-5 years I had become a podcast devotee. Listening to various podcasts

, I understand the various styles. Here are my three categories. Some podcasts resemble magazine articles. Good examples are Malcolm Gladwell’s Revisionist History , Adam Grant’s Work Life, Adam Rodman’s Bedside Rounds and CoreIM. These are heavily produced and scripted. Next are the bar discussions. In these a group discusses a topic, sometimes with questions. The Curbsiders and Freely Filtered have this vibe. Finally, we have the interview – usually a 1 on 1 conversation about a topic.

While I like all 3 types (forgive me if I omitted an important type), I personally thought I was best suited to the interview style. Back in ’08, the Annals had a deputy editor who interviewed authors about their articles. I was the guest on one of these interviews in 2009. Sore throat

Rather than try to duplicate those interviews which came out concurrently with the present issue

, we decided to pick articles both new and old from the Annals. This podcast format allows me to consider a variety of Annals articles and topics. Sometimes an article catches my eye and I consider that it would make an interesting podcast. A great example is Relationship of Interleukin-1? Blockade With Incident Gout and Serum Uric Acid Levels: Exploratory Analysis of a Randomized Controlled Trial which stimulated this podcast – Understanding Gout Pathophysiology

Sometimes I find a topic that intrigues me

, and then I look for an appropriate article. A great example is diagnostic error. I wanted to interview Dr. Hardeep Singh, so I searched the Annals for an appropriate article. Lo and behold I found a 1957 article that led to Reducing Diagnostic Error

Often I peruse the In the Clinic section and find a topic that I find worth discussing. Thus far, a variety of strategies have helped me find many great topics to discuss.

The podcast has developed in ways that I could not have predicted. Many authors, when discussing their novels, mentioned that the story often goes in directions that they did not expect. So too does a podcast. My selection process has matured and hopefully improved my topic selection.

Recording and producing each podcast is somewhat time-consuming. I spend a couple of hours each week reading the Annals, looking for appropriate topics. I focus on topics that I find interesting, either because I want to better understand the topic (think the gout pathophysiology podcast) , or because I find that learners often have some difficulty with the topic (think diuretic resistance and acute kidney injury).

Once I have picked an article, I need a discussant. I vary these with people that I know, colleagues at my institution and authors (sometimes a discussant fits more than one of these categories). So I email or call a person to see if they are willing to spend some time discussing the article(s).

Once we pick a date, I reread the article and develop an outline of the topics that I think we should cover. I share this outline with the caveat that the discussion sometimes raises more questions. This process usually takes another hour or so, although I am not counting thinking time, as I often ruminate over a topic for several days prior to developing the outline.

The day of recording, we spend less than an hour talking. My philosophy is to provide the listeners the conversation, mostly unedited. I do not use excerpts to make my own points, but rather to allow the conversation to go where it takes us.

I then spend around 2 hours listening to the recording (I use Skype and Call Recorder), doing minor editing, pick out excerpts (teasers) to put in the intro, and developing my intro and outro (Bob’s Pearls). I use Audacity for these tasks.

Finally the great staff at the Annals (I must give a shout out to Patrick Whelan, Thomas McCabe and Bernie Turner) add the music and sound effects. They released the podcast to all the podcast providers and publish the links on the Annals website. Dr. Christine Laine provides valuable feedback and input. She also writes the questions that allow listeners to gain both CME and MOC credits if they are ACP members.

Thus I estimate 5-6 hours spent per episode.

When I started I had great hopes that we could create a worthwhile podcast. After a year, I am encouraged with many great comments from listeners and colleagues. I now recommend specific episodes to my students, interns and residents.

I have a new, greater appreciation for the power of podcasts in medical education. We aspired to create something both entertaining and educational. I think we exceed my original expectations. I am so grateful to Christine for giving me this wonderful opportunity. The guest experts have graciously donated some time to have these discussions teaching me and many listeners.

So I plan to continue indefinitely. I hope the podcast helps listeners understand the wealth of Annals’ articles. And if you listen, thanks so much. I will try to make every episode worth your time.

Podcasts for UME, GME, CME – rationale


Category : Medical Rants

Readers know that I have become rather obsessed with medical podcasts over the past 2 years. I host Annals on Call

, and have appeared on The Curbsiders and the Clinical Problem Solvers. I admire Bedside Rounds and CoreIM in particular.

As I talk with students and residents

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, the enthusiasm for medical podcasts is growing and exciting. I personally get excited that our learners find podcasts a wonderful way to expand their medical knowledge. My peers listen to many podcasts. We often recommend podcasts and especially individual episodes to each other and our learners. Just yesterday we had a patient with true syncope. I immediately thought of a Clinical Problem Solvers episode – and shared the link with the students and interns.

Given our increasingly crazy schedules

, learners cannot always attend even the best conferences. Some days are just so busy, that we cannot spend the time going to a conference.

Podcasts fit into our personal schedule when we want to listen. They cover a wide variety of medical topics. Often several podcasts will address the same topic in different ways. This allows us to hear different viewpoints on a topic.

We can listen to important podcasts more than once.

This asynchronous learning opportunity fits with commuting, running, walking, or even just sitting around at home. The flexibility of podcasts fits our lives when we are ready for them.


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, who develop podcasts, therefore have a great responsibility to provide our listeners high quality episodes. Like any conference, some episodes are better and more interesting than others. With podcasts, we can share our favorites with each other and our learners.

The American College of Physicians is now sponsoring CME/MOC credits for 4 podcasts. This demonstrates a response to ACP members. Many of my colleagues listen and use this opportunity to maintain their CME and/or MOC.

If you are not yet listening to podcasts, give a few a try. Feel free to ask me for my favorites. I love this movement!