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, 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, 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.

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, 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.

We, 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!

Setting expectations for new clinical learners


Category : Medical Rants

Monday morning we have new interns and new 3rd year students. During rounds I will set expectations for their first clinical rotation at these levels. (I also have a new 3rd year resident, but he has had all 2nd year to learn how to be a resident).

What should I expect; what should they expect? In setting expectations we should try to remember our own experiences and feelings. They will be very excited and a bit scared. The interns are really doctors now, and feel that responsibility. Many have the impostor syndrome. The 3rd year students really are “newbies”, as the 3rd year of medical school has little in common with the first 2 years.

The first thing I tell them is that our job (the resident and me) involves helping them grow. We do not expect them to know how to fit their new roles, and it is our job to help them grow. We are not as concerned with their current state of knowledge as their ability to grow and improve consistently.

We will give you immediate feedback. We will teach you how to present so that the listeners know how hard you have worked on the history, physical and understanding the patient. We expect that you will need much feedback to grow.

We will ask many questions to gauge your knowledge. The questions will mostly focus on the basics. This month is all about learning the basics and trying to own them.

Learning internal medicine is difficult. We all try to learn more even at the PGY42 year (like me). Keep a notebook, or a file in your smartphone. Pick 2 things each day that our patients helped us learn. Spend around #5goodminutes reinforcing the learning from rounds. Refer back to those notes because remembering what you learn is very difficult!

We will support your growth. We expect you to work hard, but also set aside some personal time each day if possible. Take care of your mind and your body. Try to eat well. Exercise regularly. Do some things outside of medicine especially on your off days.

You will be amazed at how much you learn this year. We are here to help you. The system works. It has worked for more years than I can remember. Patients are our best teachers. Learn from them and thank them for the privilege of being part of their medical team.

Learning internal medicine really is a life long journey that never stops amazing me. You will see so much, but remember that the most interesting conversation topics will only be interesting to other 3rd year students, perhaps 4th year students, interns and residents. What you learn and know are difficult to share with non-medical friends and family. I often tell friends that they do not want to hear what I see and know.

Support each other. Internal medicine is a team sport. The best students, interns, residents and attendings make everyone around them better. We will do our best to role model all these expectations.

Congratulations, this is the most exciting, challenging, rewarding, frustrating, tiring year of your education!

Understanding diagnostic excellence


Category : Medical Rants

When we think about clinical reasoning, most talks focus on diagnostic errors and the reasons for those errors. The legacy of Kahneman and Tversky focuses on errors and the many named mistakes we make. We focus on avoiding errors, but their work and too often our teaching does not focus on the road to diagnostic excellence.

Gary Klein, the pioneer of naturalistic decision making, has focused more on the road to excellence. These are not two sides of a coin, but rather separate important concepts for us to understand. The road to excellence is likely more challenging than the road to avoiding errors. The road to excellence develops “instincts” and type 1 reasoning. The excellent diagnostician feels uncomfortable first, and then can explain why. That diagnostician must resolve the uncomfortable feeling.

The problem arises from the complexity of human beings, interviewing skills, physical diagnosis and test interpretation. As I reconstruct my best diagnostic coups, the road to the correct diagnosis is rarely straight. Each diagnostic triumph takes a different looking path.

The first step towards diagnostic excellence requires an understanding that the simple assumptions (or at least previous assumptions) might need revisiting. Once we recognize the need to reconsider the diagnosis, then we have to use many skills.

Experts attack the diagnostic process like jazz artists attack a musical performance. In order to be a great jazz musician, you must first master the basics of your instrument, an understanding of scales, keys and tempo. Only then can you successfully feel the proper notes to play.

Likewise, learning to retake the history, refocus the physical exam, and reconsider test interpretation, requires that we know the basics, understand illness scripts, and then have the ability to think without hindrance of previous proposed diagnoses. The great jazz artist plays off other musicians. The great diagnostician plays off the data to reconsider diagnostic possibilities.

We all know great diagnosticians. Every medical school has these individuals, who seemed gifted. But like great jazz, while we know it when we hear it (think Miles Davis’s Kind of Blue), we have difficulty explaining or measuring this excellence.

Like jazz or art, diagnostic stars emerge from hard work on the basics, and an ability to listen to their own discomfort with the diagnostic status quo.

Likely, we will never really be able to “measure” diagnostic excellence. Artificial conferences like CPC and CPS can showcase some of the reasoning skills, but the omit the skill of getting the patient to retell the story and ask the key questions. They omit the ability to “read the patient’s body language”.

Many strive for diagnostic excellence, and some achieve it. It requires one to approach all clinical situations with appropriate, healthy skepticism. It requires one to challenge ones own assumptions, as well as others. But this skepticism is necessary to take that road less traveled. We must understand that the diagnostic process rarely resembles a symphony because it most often requires improvisation, like the jazz greats.

Things that bug me – telling me normal (CBC, BMP)


Category : Medical Rants

Dr. Rabih Geha’s excellent post on Closler – Every Piece of Data Matters – has stimulated much thought. He makes one important point that I would like to expand.

My mind finds it much harder to attach diagnostic significance to pertinent negatives. Even if their impact on a diagnostic hypothesis is equal, I find that a positive test result sways my reasoning more so than an equally impactful negative test.

My students and residents know that I want to hear the numbers. Sometimes normal is not normal. Sometimes seemingly normal gives clues.

The problem comes from our laboratory definition of normal.The lab uses large data sets to estimate a “normal” range. Sometimes the clinical condition says otherwise.

Several years ago I had a patient with an unknown “pneumonia” who was not improving. On examining his labs I noted that his creatinine has risen from 0.8 to 1.2. Both numbers were technically normal, but a 50% increase in creatinine should grab out attention. When we finally obtained a urinalysis, he had evidence of acute glomerulonephritis. The “pneumonia” was really GPA.

What is a normal platelet count? What is a normal WBC? How do we interpret a serum calcium if we do not know the serum albumin? What does it mean when the BUN is 2? What is the BUN/creatinine ratio – and does that help us understand the patient’s story?

The patient has a history of severe vomiting, but has a normal bicarbonate level. What is the anion gap? Does the computer flag an abnormal anion gap?

When students present, I expect to hear the numbers. When reading MKSAP questions or reading (or listening to) Human Diagnosis Project cases, too often labs are reported as normal. Yet the numbers may still provide some value.

So here is my call for presenting the numbers and let me decide if they provide information. Perhaps I can teach the team something from these labs. But let me decide if the numbers are actually normal. Please!

Mystery novels, cold cases and the diagnostic process


Category : Medical Rants

Currently listening to David Baldacci – Redemption. The mystery novel, like many others, demonstrates important diagnostic principles.

The story is one of missed diagnosis – in the mystery the detective is asked to reopen a case. Once he reconsiders his first murder case (13 years later), he recognizes mistakes that he made. He carefully reanalyzes several pieces of evidence considering how they fit the original assumptions.

Once he decides that he needs to reinvestigate, he returns to the scenes of the crime. He re-examines the evidence; he once again interviews potential suspects; he focuses on inconsistencies.

In medicine we should do that regularly. When in doubt, return to the patient, retake the history and physical examination. Ask yourself, if the current diagnosis is wrong, what else could be the proper diagnosis.

When asked about another detective for whom he has low regard, he opines that the other detective is adequate but prone to focusing on the easiest explanation, and ignoring the inconsistencies.

This reminds me of an Agatha Christie quote:

“It often seems to me that’s all detective work is, wiping out your false starts and beginning again.”

“Yes, it is very true, that. And it is just what some people will not do. They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant.”
? Agatha Christie, Death on the Nile

We can learn much about diagnostic errors and the diagnostic process from mystery fiction. To do so requires that we relate the detective process to our own diagnostic process. This seems like a natural progression, since being an internist starts with detective work. Remember that many of your best diagnostic successes come on “cold cases”. As in this book, when a previous diagnosis does not make sense, consider reopening the diagnostic process as a “cold case”.