A faithful reader writes:

What drug or therapy released in the last 10 years has had the greatest positive impact?

This question stumped me for several days.  I tried to think of a new drug that I use a great deal.  Most new drugs now have important niches.  I considered rifaxamin for hepatic encephalopathy, ceftaroline for complex skin infections or dabigatran for anticoagulating patients with atrial fibrillation.

I thought, and this morning the answer came.  The most important advance in the last 10 yrs is the Walmart $4 drug list!  Several things about this list.  They have forced every competitor to have a similar list.

Prior to the Walmart list, patients paid more for generics and were more resistant to taking generics.  Walmart branded generics!  They, almost single handedly made generics acceptable to the great majority of patients.

Most important, they gave us an option to treat poor people.  We see so many patients who have poor adherence because their medications are so costly.  When we are discharging patients and tell them that we will prescribe all Walmart drugs we often see tears of joy.  Patients worry about money and Walmart and their competitors have given us the ability to give them good news about buying their meds.  

So I have changed the question a bit, but believe I have written the proper answer.

A reader sent this to me anonymously:

Healthcare-acquired pneumonia has been ruled out based on the following

reasons.  The first is that the patient's respiratory status has not

worsened over the past month while he has been on treatment.  Secondly, the

patient is afebrile.  Thirdly, the patient has normal WBC count of 8.2 and

normal neutrophil count of 72.5.  Thirdly, the chest x-ray is normal and

has no acute sign of infiltrate.  Fourthly, the patient has a normal

lactate of 0.9 and fifthly, the patient is alert and talking and is not

septic in any way and sixthly, on auscultation there are no significant

rales.  Thus, the cefepime and vancomycin which were administered in a

timely fashion in the emergency department will not be continued after

hospitalization.

The quote speaks for itself.  The physician who wrote this obviously worried that someone would question his/her decision making.  This seems a bit over the top, but ironic.

A colleague wrote:

Has blogging been an interesting side note to your career as an academic professor in medicine or has it been a more integral part of your own professional development?

I was already quite successful in my academic career, but I still believe that blogging has enhanced my effectiveness.  So what has blogging done for me?

First, I had incomplete writer's block.  While I wrote articles occasionally, I was slow, and avoided writing most of the time.  Blogging changed this dramatically.  Because I write most days, my writing has improved dramatically.  

Almost all books on writing give the advice of writing daily to improve one's writing.  Perhaps the main reason I started blogging was just to improve my writing.  I write much more quickly and much more easily.  Like everything else writing improves with practice.

Second, blogging has allowed me to explore ideas.  I think about more things because I am always exploring potential ideas for this blog.  Some of these ideas have attracted attention and led to editorials.  Some of these ideas matured and became articles.  Blogging is my idea laboratory.  When my ideas have flaws, readers point out those flaws.  When the ideas have strength I get "attaboys".

Finally, blogging has established my "brand" for those who might not have known me.  At medical meetings colleagues and trainees often tell me that they read my blog and enjoy my screeds.  I have met some wonderful colleagues because of blogging.  

Blogging has exceeded my expectations as I recall them in 2002.  All the above are true, but even if not, I would probably still blog because it has become a very enjoyable hobby.

I got asked this question:

How can pharma companies work collaboratively with health bloggers? What's needed?

On this blog it is not happening.  No pharma, no device companies, no requested guest blogs.  No collaborations!

In my opinion, one must take blogging seriously or just forget about having the blog mean anything.

I have written extensively about pharma, and mostly negatively.  While I appreciate their research and the important drugs they develop, I markedly dislike their marketing and their frequent lack of ethics. 

So how could I work with them?  Simple story, I cannot.

I started this blog May 19th, 2002.  Explaining longevity is subjective.  Mostly, I like blogging.  I find it fun to put my ideas into words.  Some have asked me how I get so many ideas.  I read other blogs, some journals, the NY Times Health section and I see patients.  Ideas come from all those and more.  Sometimes an idea comes from a conversation that I have with a friend.

Many of my ideas repeat, after all how many different subjects do we have to address.  But even with an old idea one can find a new angle.  I try to do that regularly.

I vary topics from policy to medical education to clinical topics.  I do that because I find all of them interesting.

Basically I blog with myself in mind, and am gratified that others find my comments interesting.

Early, I was obsessed with daily blogging, now I will go a couple of days without blogging if life makes blogging difficult.  Still, I do find time most days.

Blogging is never a chore.  One cannot last 10 years doing a chore.  Rather this blog is my personal soapbox.  Thanks for gathering around while I scream at the injustices and praise the wonders of my most fortunate career.

Yesterday was a long day.  I spent much time mentoring and talking.  Viewed many posters, both research and clinical vignettes.  Had some meetings, both formal and informal.

Participated in a tweetup.

Went to a nice Presidential reception.  Back to my room I crashed.

Meetings are fun and tiring.

While going around the posters, several residents mentioned that they follow me on twitter and read this blog.  They were complementary and made a point to encourage me to continue presenting patient stories and reflecting on internal medicine.

I think these comments were the highlight for me.  Some people have wondered why I spend time doing social media.  The reason we do it is because we are communicating.  Sometimes while typing I wonder if my words matter to anyone but me.  Apparently they do.

An underlying theme for junior academic internists involves how to structure their career.  This advice pertains to academics only.  We each have to determine what we like doing and what we love doing.  Then we must work to get rid of the stuff we like doing, so that we can spend more time on those things we love doing.  We must become great an relatively invaluable (note that no one is completely irreplaceable, but rather the replacement can be painful).  You should strive to bring extra value to your group.

Now I'm off to the past-president's breakfast.  Then I will finally be able to go to some sessions!

During my poster perusal, I saw a couple of excellent posters on teaching attendings.  The best attendings go to the bedside and interact with the patient, doing history or physical components as necessary, and making certain that the patient knows the plan for the day.  The attending has residents and students with them.

I discussed these poster with several people.  Are these activities not obvious?  Who would not do this?  But several long time friends bemoan their ability to take the learners to the bedside.  They say the residents do not have time.

That comment makes no sense to me.  How can the residents not have time?  Perhaps that explains part of the problem I referred to on Monday – not enough attention on the basics.

I pre-round with the team, sitting in a room and hashing out ideas, looking at films, reviewing the lab data and hearing the history and physical exam.  Then we go see all the patients.  I believe we learn much at the bedside.  I cannot imagine not going to see the patient.

What has happened to training?

Standing in line to check into the hotel – the Disney Dophin and Swan – someone asked me how many meetings I had attended.  I answered 30 or 31.  SGIM has had a great influence on my academic career.  Because of SGIM I have friends all over the country.

Today I went to the poster session that really started the meeting.  Tonight I viewed research posters and talked with many old friends, and some new ones.

This year I will go to some research, but really focus more on clinical vignettes.  As time goes on, I find the clinical vignettes very valuable in learning how to approach difficult diagnostic problems.

For those following on Twitter – use the hashtag #sgim2010 – like in the title of this post.

In 11 days I will celebrate 10 years of medical blogging.  To celebrate this achievement, I invite readers to "interview" me though questions.  This is your chance to ask me anything – about blogging.

Thanks in advance for your questions!

Over the past decade the ACGME has focused on the six competencies:

1. Patient Care
2. Medical Knowledge
3. Practice Based Learning and Improvement (self improvement)
4. Interpersonal and Communication Skills
5. Professionalism (basis for all physician skills)
6. Systems Based Practice (working with the health care system)

Now I do understand that these competencies have some underlying validity.  But I wonder whether we have forgotten the basics.

Maybe I am just an old fogie, but before we worry about the competencies we must teach the basics and students and residents must learn them.  The basics are the foundation of good medicine:

1. Take a complete, relevant, accurate history
2. Do an appropriate physical examination
3. Order the correct laboratory tests and interpret them fully and accurately
4. Order the correct images and interventions and interpret them
5. Repeat the above as necessary

The reason that I obsess over these issues is that we have an obligation to diagnose accurately.  Each of these steps is crucial.  

Too often we in medical education do not spend enough time teaching history taking.  Too often we skim over the physical exam.  Too few trainees can interpret completely laboratory tests.

I am using a bit of hyperbole here.  But my accusations do have some basis in experience.  

So why do we underemphasize these basics.  Are we distracted by performance measures?  Do we rely too much to "man scans"?  

What do you think?  Am I exaggerating too much?  As this a faux problem?