Medicine

In medicine, unlike much of the world, it is the questions one doesn’t ask that lead to trouble. When taking a medical history, the biggest enemies are time and fear. Time, because there is never enough to ask all the questions, listen carefully to all the answers, and pursue all the possible clues. Fear, because the natural reluctance to ask certain questions is a trap.

I was taught that being an asymptomatic carrier of strep in the throat was not associated with either illness or risk of complications. That’s not always true. The schedule said ‘strep throat x 5 weeks and diarrhea.’  Handing me the encounter form, my nurse warned me: ‘Mom’s not a happy camper.’

Teaching to the test is controversial. It helps students pass tests and makes educational programs look successful, but everyone knows it does not guarantee improved education.  

After reading this excellent study in the BMJ showing no benefit and some risk of harm from annual mammographic screening for breast cancer (see also this discussion in the NY Times) I suggested to a local institution that they should reconsider their Pay for Performance (P4P) initiative which penalizes their clinicians (by lowering their pay) if thei

Quality in the EHR is a zero-sum game, involving a balancing act among three key but competing needs: scope, resources and usability.

It seems I come across a pessimistic article like this at least once a week.

It’s about the patient. All about the patient. Only about the patient.

I just don’t understand the way we order radiologic tests and procedures. 

If I discover skin cancer during an office visit, I refer the patient to the dermatologist or surgeon for evaluation and treatment. I don’t have to order the specific procedure they will do, or fill out a prior authorization form for their biopsy or excision.

Doctors often complain that patients indulge in maladaptive magical thinking and talk about how hard it is to get them to face reality. Sometimes, it is easier to join patients in their magical thinking.

I remember an incident from an Emergency Medicine clerkship during my fourth year of medical school. I was asked to see an agitated young man whose ED chart said: “Chest pain, agitation, hallucinations.”

Anne came in for her annual health maintenance visit with great news. Her irritable bowel syndrome was no longer a problem. “I hope you aren’t upset with me, but I’m cured.”