"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow
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Workouts by month - Goal 200 from 11/1/09 through 10/31/10
The ACP Advocate Blog by Bob Doherty: "There once was a man named O'Bama ..." http://ow.ly/1nUH3 - HCR limericks and a cold one for BobMarch 18, 2010 5:24
http://ow.ly/1mYi7 - ABIM MOC program - two differing viewpoints - you can guess my voteMarch 16, 2010 5:06
RT @yejnes: My thoughts on the annual exam, etc., final letter ACP Internist, March 2010 http://bit.ly/9FNcXn wel-stated & importantMarch 15, 2010 12:47
A note to the professors, from the "real" world, on the use of ICDs in a fee for service community... http://ow.ly/1jaPy - great postMarch 13, 2010 2:19
RT @paulinechen: New "Doctor and Patient"; Learning to Keep Patients Safe in a Culture of Fear http://nyti.ms/bYA14V - blog post comingMarch 12, 2010 1:35
RT @tom_peters: @kevinmd Spoken like an MD. - true primary care is very complex - it is not simple care -March 11, 2010 12:43
RT @efalchuk: Seriously, what is Nancy Pelosi Talking About? http://bit.ly/9sHSc2 #healthreform #hcr #healthcare think Dazed and ConfusedMarch 10, 2010 7:53
Obama Says Health Overhaul Should Trump Politics - http://nyti.ms/bwKRyo - and he is correctMarch 8, 2010 7:28
I am currently attending the Canadian Society of Internal Medicine meetings in Toronto. I had occasion to chat with Dr. David Sackett (of clinical epidemiology fame). We were discussing GIM from an international perspective.
He pointed out that general internists develop skills in “sorting out” a patient’s problems, medications, etc. In contrast, subspecialists tend to develop skills in “ruling out” their organ system.
While this distinction is a bit pithy and cute, I like it a great deal – and plan to use it often. We have a difficult time developing quality measures around this important skill. Yet, many patients arrive at our hospital or office without a diagnosis. Therefore, our greatest skill is undervalued because it is so difficult to measure.
Not only general internists, but also general surgeons follow the “sorting out” criteria. I agree that not enough credit is given to these potential diagnostic dilemmas. Nonoperative determinations are just as thought provoking (and angst-producing) as “taking a patient to surgery” and yet the reimbursement does not adequately consider the cognitive process involved by the surgeon.
I think this is also what seperates out the physicians from the midlevel providers. Some nurse practicioners claim they can do as good a job as primary care docs. I think they can make some claims in this area when the diagnosis is certain and there are well designed clinical protocols for management. The mistakes I see them making though are when the diagnosis has not been made yet, when the disease has an unusual presentation, or when there are complications or unexpected response to treatment. The length of their training doesn’t expose them to enought variation and amount of pathology. As the old saying goes – “you can’t diagnosis it if you’ve never heard of it”. I think this is one of the areas where primary care physicians shine.
I went to the PCP the other day with all the lymph nodes on the left side of my head swelled up, a fever, and weakness on the left half of my body. She told me it was TMJ and I had no infection, told me the lymph nodes weren’t swollen. Rather odd as I live in this body every day and I don’t normally have painful puffy lumps where my lymph nodes are. TMJ is some crazy stuff.
I have to say that previous interactions with NPs have been better than with MDs. They have more time to listen and are willing to say “I have no idea”. Time is the factor. The PCP was so busy not listening that she gave me an answer that makes no sense. Every visit is about getting me out the door quickly with as many meds as possible. I didn’t need meds the other day. I needed to make sure I didn’t have menengitus or something else really odd that I would be unaware of.
Now other people in the office are feeling sick so it seems my TMJ is contagious.
I am actually looking for an NP or something along those lines as I need to in the care of someone who can stop and think for a minute and listen to me without questioning everything I say.
My experience with endos confirms the above ruling out phenomena. When Dr. Satan ruled out the endocrine system as the root of the problem she was at a loss. She sent me to a cardiologist and then wanted me to go to a neurologist. She had no ability to think in a global way. The cardiologist could only tell me “it’s not your heart-its something endocrine”. Did these guys miss out on the rest of med school or something?
Diagnsotic skills all require careful attention and time to interview, examine, test and rexamine. low Reimbursements unfortunately discourage this.
as for diagnostic skills offerred by a MD/DO or NP ?
some MD’s/DO’s are great, some are terrible.
some NP’s are great, some are terrible.
New England journal of medicine recently had an article showing that Pt’s hospitalized late in the week had increased risk of having a bad outcome. This indicates the fact that people do get fatigued and fatigue can influence the quality of health care.
no surpise here…but this does highlight how other influences other than professional degree affect outcomes.
Tina , good luck with your search for a good provider.
It cannot be ignored, that nearly all Breast Cancer Tumors occur in the upper outer quadrant of the breast area, this is where the Lymph Nodes are located..
5 Responses to Sort out vs rule out
matthew md
November 4th, 2005 at 6:44 pm
Not only general internists, but also general surgeons follow the “sorting out” criteria. I agree that not enough credit is given to these potential diagnostic dilemmas. Nonoperative determinations are just as thought provoking (and angst-producing) as “taking a patient to surgery” and yet the reimbursement does not adequately consider the cognitive process involved by the surgeon.
Dr. Bob
November 6th, 2005 at 5:40 pm
I think this is also what seperates out the physicians from the midlevel providers. Some nurse practicioners claim they can do as good a job as primary care docs. I think they can make some claims in this area when the diagnosis is certain and there are well designed clinical protocols for management. The mistakes I see them making though are when the diagnosis has not been made yet, when the disease has an unusual presentation, or when there are complications or unexpected response to treatment. The length of their training doesn’t expose them to enought variation and amount of pathology. As the old saying goes – “you can’t diagnosis it if you’ve never heard of it”. I think this is one of the areas where primary care physicians shine.
tina
November 8th, 2005 at 1:08 pm
Hi Dr.Bob,
I went to the PCP the other day with all the lymph nodes on the left side of my head swelled up, a fever, and weakness on the left half of my body. She told me it was TMJ and I had no infection, told me the lymph nodes weren’t swollen. Rather odd as I live in this body every day and I don’t normally have painful puffy lumps where my lymph nodes are. TMJ is some crazy stuff.
I have to say that previous interactions with NPs have been better than with MDs. They have more time to listen and are willing to say “I have no idea”. Time is the factor. The PCP was so busy not listening that she gave me an answer that makes no sense. Every visit is about getting me out the door quickly with as many meds as possible. I didn’t need meds the other day. I needed to make sure I didn’t have menengitus or something else really odd that I would be unaware of.
Now other people in the office are feeling sick so it seems my TMJ is contagious.
I am actually looking for an NP or something along those lines as I need to in the care of someone who can stop and think for a minute and listen to me without questioning everything I say.
My experience with endos confirms the above ruling out phenomena. When Dr. Satan ruled out the endocrine system as the root of the problem she was at a loss. She sent me to a cardiologist and then wanted me to go to a neurologist. She had no ability to think in a global way. The cardiologist could only tell me “it’s not your heart-its something endocrine”. Did these guys miss out on the rest of med school or something?
matte
November 9th, 2005 at 1:52 am
Diagnsotic skills all require careful attention and time to interview, examine, test and rexamine. low Reimbursements unfortunately discourage this.
as for diagnostic skills offerred by a MD/DO or NP ?
some MD’s/DO’s are great, some are terrible.
some NP’s are great, some are terrible.
New England journal of medicine recently had an article showing that Pt’s hospitalized late in the week had increased risk of having a bad outcome. This indicates the fact that people do get fatigued and fatigue can influence the quality of health care.
no surpise here…but this does highlight how other influences other than professional degree affect outcomes.
Tina , good luck with your search for a good provider.
lymph nodes
March 18th, 2008 at 8:46 am
It cannot be ignored, that nearly all Breast Cancer Tumors occur in the upper outer quadrant of the breast area, this is where the Lymph Nodes are located..