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 ..read more

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, 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 grea ..read more

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 ..read more

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, 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 becaus ..read more

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 ..read more

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. On treating medical students with respect And this one Tips for IM ward attendings – Chapter One – servant leadership The pr ..read more

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 differ ..read more

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 gen ..read more

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 ..read more

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 w ..read more