Robert Centor posted an article on DB’s Medical Rants - Feb 11, 2012, 8:09 am
To restate:   35-year-old man admitted for worsening ascites. We know the patient because he had just left AMA 3 days before.  He had HIV with a low CD4 and did not take any anti-retrovirals.  He also had hep C cirrhosis with encephalopathy and worsening ascites.  He did take spironolactone an...
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Robert Centor posted an article on DB’s Medical Rants - Feb 9, 2012, 6:44 am
35-year-old man admitted for worsening ascites. We know the patient because he had just left AMA 3 days before.  He had HIV with a low CD4 and did not take any anti-retrovirals.  He also had hep C cirrhosis with encephalopathy and worsening ascites.  He did take spironolactone and lactulose and t...
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Robert Centor posted an article on DB’s Medical Rants - Feb 7, 2012, 12:38 pm
Regularly readers know that I am currently fascinated with Gary Klein's work.  I am currently writing a discussion for a clinical problem solving exercise.  Using Klein's work, I learned the value of mental simulation that he labels a "pre-mortem" examination.   After we see the results of a dec...
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Robert Centor posted an article on DB’s Medical Rants - Feb 6, 2012, 11:36 am
Throughout my career I have worked as a medical school faculty member.  I took my first job with the naive belief that my main job involved teaching medical students and residents.  Over the years I have learned that those who do this job extremely well still may not advance, unless they do the ot...
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Robert Centor posted an article on DB’s Medical Rants - Feb 5, 2012, 8:51 am
We who work in hospitals know that most hospitals do not work as well on weekends as during the week.  I have worked at several hospitals over the years, and every hospital is understaffed on weekends. Patients 'more likely to die' if admitted at weekends The study, in the Journal of the Royal So...
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Robert Centor posted an article on DB’s Medical Rants - Feb 3, 2012, 9:23 am
Early in my academic career I became fascinated with decision analysis.  I still like decision analysis as a strategy to make explicit the structure of a problem.  However, over time the major weakness of decision analysis became very clear.  The problem derives from the assumptions. As usual, I...
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Robert Centor posted an article on DB’s Medical Rants - Feb 2, 2012, 12:51 pm
This week my team presented a patient who had puzzled them.  The patient complained of 3 weeks of facial swelling.  She had diabetes mellitus type II with severe gastroparesis.  She had both a feeding tube and a port (she used the port for saline boluses when she became volume contracted). She h...
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Robert Centor posted an article on DB’s Medical Rants - Jan 31, 2012, 8:23 am
When discussing cognition intuition does not refer to ESP, rather definition #3 in dictionary.com - a keen and quick insight.  Physicians use this form of intuition often.  We learn patterns and use pattern recognition to make quick diagnoses and decisions.  Sometimes we call these patterns "il...
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Robert Centor posted an article on DB’s Medical Rants - Jan 30, 2012, 4:31 pm
Time to share a frustration.  While some diseases and symtoms have clear causes, not all do.  If you smoke for 30 years, 2 packs a day, and develop COPD, or coronary artery disease, or lung cancer, then I know why.  If you drink 2 pints of vodka daily and develop cirrhosis, I likely know why.   ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 29, 2012, 6:21 pm
Bravo!  As regular readers know, ACP is championing high value, cost conscious care.  Browsing some blogs today I find that the American Journal of Medicine has started a new feature that physicians should consider when trying to provide HVCCC.  Here is the editorial introducing this new feature ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 26, 2012, 9:17 pm
Several readers nailed this one – valproic acid (Depakote).  Valproic acid does cause hyperammonemia This syndrome can occur with overdoses, but can also occur on apparently stable dosing.
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Robert Centor posted an article on DB’s Medical Rants - Jan 26, 2012, 5:15 am
High Value Cost Conscious Care does not just represent a slogan.  HVCCC represents an attitude.  We at ACP believe that physicians can help decrease health care costs.  We see waste in the system and will do our best to decrease the waste. Yesterday I tweeted - Appropriate Use of Screening and ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 25, 2012, 6:14 pm
Patient admitted after apparent overdose.  Patient does not respond to verbal stimuli or tactile stimulation. Patient has known schizophrenia. Exam comatose, VS T 99, P 80, R 18, BP 130/80 Otherwise exam is unremarkable Labs 143 103 22 82 3.9 23 1.0 9.6   WBC 7.9 Hgb 12.9/ Hct 37.1 Plt 194 ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 21, 2012, 9:19 am
First, a disclaimer – I am biased.  I have spent 30 years thinking, researching and writing about adult pharyngitis.  My success in that field has stunned me.  Of course I will overemphasize all arguments in favor of my opinion and poo-poo those in opposition. The advocates of the rapid strep ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 20, 2012, 8:09 am
... , this stuff is much more complex than these demonstration projects can address.  Physicians really do their best out there. We should modify our payment system.  First, we must make our payment system ... based.  We have too many patients seen too quickly.  Second, we should invest in the...
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Robert Centor posted an article on DB’s Medical Rants - Jan 17, 2012, 5:51 pm
We all learn a "checklist" of history questions.  This list has no prioritization and many students work at memorizing the list. Clinicians actually do prioritize questions.  Over the years I have identified 2 very useful questions.  These questions help me in a wide variety of questions. 1. Wh...
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Robert Centor posted an article on DB’s Medical Rants - Jan 15, 2012, 11:06 am
During the first 2 years of medical school we study basic sciences.  We learn biochemistry, physiology, histology, anatomy, pharmacology and microbiology. Jerome Kassirer, in a wonderful Academic Medicine essay,  These concepts foster the teaching and learning of the diagnostic process, the compl...
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Robert Centor posted an article on DB’s Medical Rants - Jan 13, 2012, 4:15 pm
After one has done a good history and physical exam and reviewed the labs, sometimes imaging helps us.  The master diagnostician has several responsibilities.  The diagnostician should order the appropriate test and review the results.  When confused one should go to radiology to discuss the resu...
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Robert Centor posted an article on DB’s Medical Rants - Jan 9, 2012, 9:48 am
Thanks for the comments that have encouraged me to expand on the previous post. 1. Often we obtain labs in response to the patient's history and physical examination.  We should understand how different lab tests might help us, and what the indications are for ordering those tests. 2. Often when ...
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Robert Centor posted an article on DB’s Medical Rants - Jan 5, 2012, 8:19 pm
While we can diagnose many patients based on history and physical exam, sometimes we must turn to the lab for help. Physicians order lab tests regularly.  However, many experts believe that too often we do not alway interpret the lab tests.  Over 3 years ago I linked to this article - Test confu...
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Robert Centor posted an article on DB’s Medical Rants - Jan 4, 2012, 4:50 pm
During the first 2 years of medical school we take a course on the physical examination.  Most courses present a laundry list of exam processes.  During our 3rd year we do many exams.  Despite this training, few interns have physical exam proficiency. While occasionally a "complete history and p...
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Robert Centor posted an article on DB’s Medical Rants - Jan 3, 2012, 9:59 am
Before entering medical school, I remember an adult (I was then an adolescent) praising a physician as being a great diagnostician.  During medical school the diagnostic process grabbed my attention and my love.  My obsession with diagnosis started then.  During residency, I continued my quest to...
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Robert Centor posted an article on DB’s Medical Rants - Jan 1, 2012, 6:26 pm
Happy New Year!  In reflecting on my blogging over the past year, I considered many issues.  The evidence against P4P continues to mount.  The biases in guideline development have gained more widespread interest  Retainer medicine continues to grow (and I co-authored an opinion piece on this top...
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Robert Centor posted an article on DB’s Medical Rants - Dec 30, 2011, 9:16 am
Danielle Ofri has a wonderful piece in today's NY Times - The Provider Will See You Now: Still, the term “provider” has never stopped irritating me. Every time I hear it — and it comes only from administrators, never patients — I cringe. To me it always elicits a vision of the hospital sta...
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Robert Centor posted an article on DB’s Medical Rants - Dec 29, 2011, 1:04 pm
A recent patient provides an interesting conundrum.  This patient has systolic dysfunction with an LVEF of approximately 40% and stage IV CKD (with proteinuria). The renal service wants him on an ACE-I or an ARB, while the cardiology service has written in a note that stage IV CKD makes ACE-I or A...
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Robert Centor posted an article on DB’s Medical Rants - Dec 14, 2011, 11:52 am
... . The delay in drainage probably made both the the procedures more complicated. I have discussed this phenomenon with several internists and infectious disease subspecialists over the past 2 days.  They all have seen this phenomenon.  One suggested MRI with contrast to convince the surgeon....
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Robert Centor posted an article on DB’s Medical Rants - Dec 13, 2011, 7:46 am
Twice in the past month I have had frustration with surgeons.  Both patients had palpable abscesses.  One could easily feel the abscesses and see the surrounding cellulitis.   I am not second guessing, because I wrote in my notes that the patients had abscesses that need drainage.  In each case...
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Robert Centor posted an article on DB’s Medical Rants - Dec 11, 2011, 9:21 am
Many colleagues attack the ACP as being too liberal.  They object to our endorsement of the Affordable Care Act, even with our stated concerns about things missing from the act and things unnecessarily in the act. We, at ACP, first create policy, then comment on issues based on our policies.  As ...
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Robert Centor posted an article on DB’s Medical Rants - Dec 7, 2011, 5:08 pm
We have exciting news.  We are accepting applications for a new internal medicine residency.  We need 8 interns and 8 second year residents for July 2012.  UAB – Huntsville Regional Medical Campus Internal Medicine Residency – a brand new residency created in cooperation with Huntsville Hospi...
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Robert Centor posted an article on DB’s Medical Rants - Dec 6, 2011, 4:59 pm
My students and residents all know that I spout off rules.  I have never collected these Centorisms, but today I finally decided on rule #1.   Rule #1 – make a diagnosis before starting treatment.  Too often I see patients receive the wrong treatment because someone assumes a diagnosis.  Too...
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Robert Centor posted an article on DB’s Medical Rants - Dec 4, 2011, 5:50 pm
Health Official Takes Parting Shot at ‘Waste’ The official, Dr. Donald M. Berwick, listed five reasons for what he described as the “extremely high level of waste.” They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, b...
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Robert Centor posted an article on DB’s Medical Rants - Dec 2, 2011, 7:21 am
While I thought I made myself clear, I will address this issue again. Most programs have not addressed this issue adequately.  The family medicine program in Huntsville has worked hard to address the following issues.  The residents have few of these problems, but the students are somewhat disadv...
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Robert Centor posted an article on DB’s Medical Rants - Nov 30, 2011, 8:12 pm
Earlier this week I spent some time talking about medicine with an intern and a student.  They quickly challenged me about work hours.  Both of them had criticism of the ACGME rules.   So why are they upset?  The following is my interpretation of the discussion. Two major issues emerged.  Fir...
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Robert Centor posted an article on DB’s Medical Rants - Nov 29, 2011, 1:00 pm
"I cannot teach anybody anything, I can only make them think." – Socrates Despite insurance company efforts to the contrary, despite politician proclamations, despite public reporting of performance scores, successful medicine depends more on establishing the proper diagnosis than on achieving pe...
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Robert Centor posted an article on DB’s Medical Rants - Nov 29, 2011, 9:04 am
I cannot teach anybody anything, I can only make them think.
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Robert Centor posted an article on DB’s Medical Rants - Oct 30, 2011, 12:24 pm
Yesterday I tweeted an important NY Times article - M.R.I.’s, Often Overused, Often Mislead, Doctors Warn This article speaks to the major problem with diagnostic tests – they are not perfect.  This article points out the problem of false positive MRI findings. I do love diagnostic test inte...
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Robert Centor posted an article on DB’s Medical Rants - Oct 29, 2011, 5:58 am
J'accuse is a famous French term.  For the next several rants, I will point fingers at problems that decrease thinking in medicine.  Clinical judgment often requires thought.  Thinking uses energy.  Thinking is tiring.  We would rather start with intuitive (fast) thinking rather than resort to ...
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Robert Centor posted an article on DB’s Medical Rants - Oct 27, 2011, 5:09 pm
I have changed the title of the conference.  I hope that in the future we focus more on how to improve diagnostic processes and accuracy and focus less on errors (other than to use errors to inform improvement). The third day continued the ideas we explored in the first 2 days. My talk focused on...
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Robert Centor posted an article on DB’s Medical Rants - Oct 26, 2011, 7:54 am
Later this morning I will give my talk on rapid testing and clinical prediction rules. Yesterday I attended several excellent sessions, and thought a great deal about diagnostic accuracy.   The leaders of this movement announced that this meeting will evolve into a new society – the Society to ...
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Robert Centor posted an article on DB’s Medical Rants - Oct 25, 2011, 3:56 pm
Yesterday I went to many talks and discussions at the DEM conference.  These are my thoughts thus far: Wonderful keynote address by Gary Klein – author of several books including Sources of Power: How People Make Decisions His talk convinced my to get and read this paper - Conditions for Intu...
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Robert Centor posted an article on DB’s Medical Rants - Oct 24, 2011, 8:51 am
Watching Mike and Mike and Morning Joe this morning, and I am outraged.  In the last 30 minutes I have seen 2 drug ads that feature physicians speaking to patients.   Now I know that these physicians are getting paid for the ads.  I suspect they believe they are helping patients. And yet I find...
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Robert Centor posted an article on DB’s Medical Rants - Oct 23, 2011, 7:36 pm
Tuesday morning I will download Thinking, Fast and Slow to my iPad.  I do not remember being this excited about a non-fiction book. Those of you who follow my tweets know that I am obsessed finding reviews of the book and tributes to Kahneman.  We should also not forget that the late Amos Tversky...
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Robert Centor posted an article on DB’s Medical Rants - Oct 21, 2011, 7:01 pm
Next Wednesday I am speaking at the 4th Diagnostic Errors in Medicine meeting.  My talk will address the question stated above. In the past, readers have helped me clarify my thoughts.  Once again I ask you to read my thoughts and provide critique. For over 50 years, we have addressed sore throa...
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Robert Centor posted an article on DB’s Medical Rants - Oct 20, 2011, 7:00 am
While I cannot quote the studies, everyone in hospitalist leadership can quote the statistic.  The optimal daily patient number for hospitalists ranges from 15-18. Earlier this week, I had dinner with an excellent hospitalist.  He works 12 hour shifts.  He observed that when he had more than 18 ...
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Robert Centor posted an article on DB’s Medical Rants - Oct 18, 2011, 8:41 am
My friend Bob Doherty wrote a provocative piece on this subject last week - Free market health care is the answer? Then show me. I spent much time with Bob this past weekend at the Tennessee ACP chapter meeting.  We discussed this issue over beers.  Since Saturday I have thought more carefully a...
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Robert Centor posted an article on DB’s Medical Rants - Oct 16, 2011, 7:12 pm
Because he is the most profound American crime writer. I am currently listening to Feast Day of Fools narrated brilliantly by Will Patton. If you like mysteries and thrillers you must read James Lee Burke.  No one writes more poetically and movingly about American culture.  Another of my autho...
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Robert Centor posted an article on DB’s Medical Rants - Oct 16, 2011, 6:50 pm
Pamela Hartzband, M.D., and Jerome Groopman, M.D. have written a brilliant piece in the current NEJM - The New Language of Medicine.  In this piece they explain why some have adopted the term provider and customer rather than the traditional physician and patient. The words we use to explain our ...
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Robert Centor posted an article on DB’s Medical Rants - Oct 13, 2011, 9:09 am
The term vitamin carries almost magical connotations.  Taking vitamins must help us.  Wikipedia provides the origina of the term -  The term vitamin was derived from "vitamine," a combination word made up by Polish scientist Casimir Funk from vital and amine, meaning amine of life, because it wa...
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Robert Centor posted an article on DB’s Medical Rants - Oct 12, 2011, 6:24 am
Of course I love when a post creates controversy and therefore many comments.  But when the comments seem to miss the point, I wonder what has happened. This issue (and many in medicine) clearly lend themselves to controversy.  Controversy comes when data interpretation has complexity. Clearly t...
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Robert Centor posted an article on DB’s Medical Rants - Oct 11, 2011, 3:06 pm
As a regular internal medicine ward attending, I see diagnostic errors frequently.  Sometimes the patients have received an incorrect label from the emergency department; sometimes another internist or subspecialist has provided the wrong label; sometimes their primary care physician has mislabeled...
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