Leader of Curmudgeon Volunteer Force here, reporting for duty.
I learned murmurs with headphones and 78 rpm records. I always call out residents who couldn't hear the murmur until they read the echocardiogram report.
On a more serious note, "guidelines" are starting to cause serious harm. First, in addition to sausage and legislation, there is now a third thing you should now avoid watching being made, and that is guidelines, because when you see the offal shoved in, you lose trust.
This leads to problem two, which is the elimination of "no guideline can cover all contingencies, clinical judgement is still necessary". Well, the quality metric of "How fast and how completely was the guideline followed" is a tsunami that has landed on our beaches and obliterated the very notion of "contingencies". Come on! Everybody knows AI is right 100% of the time, and why? BECAUSE IT ALWAYS FOLLOWS THE GUIDELINE. I encounter young ones on rounds all the time now who actually think "I followed the guideline" should lead to a pat on the head instead of my inevitable Socratic dialogue. I use the ur-question of Internal Medicine, "how do you know that?" all the time in response to unsupported assertions - but the young ones hate that and I never accept "the radiologist told me that" as an answer.
These two problems have created the third - the business guys are 100% on board with APP + AI as the solution to increased throughput, better coding, faster discharges, and bigger margin. Outcomes? Too subjective, not standardized! Fix the process! Conform always! The operation was a success, but... You know the rest.
There are still what nurses used to call "real doctors" around, responsible for outcomes and process agnostic. But they are not being replaced. And 22,000 USMGs/year owing $300,000+ will not all be orthopedic surgeons, dermatologists, or department chairs.
Some really great advice in the posts below. I would add - don't think you know the patient's body better than the patient. Don't be dismissive of what the patient tells you. The patient has lived in their body for their whole life; your medical knowledge doesn't necessarily understand their body better than they do.
I'd highlight the last one: the patient's chief concern is not the primary problem. Like all great truths, I think the opposite is also true. The patient's chief concern is the most important thing. When I am unsure where to go next, I return to the chief complaint and use that to guide my next move. Also, if a patient comes in for a sore toe and you ignore it because they also had shortness of breath, long after their reaction to someone's perfume has worn off, they're going to be pissed to have to pay a second copay to get their gout diagnosis.
More common things happen more commonly. No need to treat everyone like a newborn sepsis work up.
Look at lab values in a range and as a trend not as absolute and how they relate to the diagnosis. A potassium below 4 on a pt with arrhythmia or on insulin therapy is not the same as when dealing with acute trauma. Know the drugs and their action on organ systems and stay ahead of them.
Vital signs reflect what’s going on in the pt’s life and not necessarily pathological. A pt in pain with elevated BP doesn’t need nifedipine sublingual ( JUST KIDDING ! )
Elixir of time is a great drug.
Think radiation exposure before ordering x-ray tests. If an ultrasound will suffice, why a CT ? CT can cause 15-100 times the exposure vs an abdominal film, even with modern dose reduction techniques. U/S is zero. Less need for pre-approval ….
You are in training. Ask for guidance when in doubt.
The medical record is a legal document, treat it as such. Re-read before closing it to avoid problems later. The original version is available despite there being an amended one.
I’d add, if you try to do everything you end up doing nothing. The patient who comes in with back pain and whose mom just passed does not need to be lectured on cancer screening, or worse, blindly given a colonoscopy referral. Or even worse discussed options on where to get Tdap so tetanus is Uptodate.
As a long time “preceptor “ of FP residents this piece rings so true. “Baseline “ bloodwork, knee jerk consultations, unhelpful testing, and “do something “ are a large part of the guidance I provide. This piece should be required reading for all docs who do this work.
Love those 3 questions about testing. I'm keeping them in my pocket for next time one of my docs orders a test!
Leader of Curmudgeon Volunteer Force here, reporting for duty.
I learned murmurs with headphones and 78 rpm records. I always call out residents who couldn't hear the murmur until they read the echocardiogram report.
On a more serious note, "guidelines" are starting to cause serious harm. First, in addition to sausage and legislation, there is now a third thing you should now avoid watching being made, and that is guidelines, because when you see the offal shoved in, you lose trust.
This leads to problem two, which is the elimination of "no guideline can cover all contingencies, clinical judgement is still necessary". Well, the quality metric of "How fast and how completely was the guideline followed" is a tsunami that has landed on our beaches and obliterated the very notion of "contingencies". Come on! Everybody knows AI is right 100% of the time, and why? BECAUSE IT ALWAYS FOLLOWS THE GUIDELINE. I encounter young ones on rounds all the time now who actually think "I followed the guideline" should lead to a pat on the head instead of my inevitable Socratic dialogue. I use the ur-question of Internal Medicine, "how do you know that?" all the time in response to unsupported assertions - but the young ones hate that and I never accept "the radiologist told me that" as an answer.
These two problems have created the third - the business guys are 100% on board with APP + AI as the solution to increased throughput, better coding, faster discharges, and bigger margin. Outcomes? Too subjective, not standardized! Fix the process! Conform always! The operation was a success, but... You know the rest.
There are still what nurses used to call "real doctors" around, responsible for outcomes and process agnostic. But they are not being replaced. And 22,000 USMGs/year owing $300,000+ will not all be orthopedic surgeons, dermatologists, or department chairs.
What then, medical schools?
Some really great advice in the posts below. I would add - don't think you know the patient's body better than the patient. Don't be dismissive of what the patient tells you. The patient has lived in their body for their whole life; your medical knowledge doesn't necessarily understand their body better than they do.
I'd highlight the last one: the patient's chief concern is not the primary problem. Like all great truths, I think the opposite is also true. The patient's chief concern is the most important thing. When I am unsure where to go next, I return to the chief complaint and use that to guide my next move. Also, if a patient comes in for a sore toe and you ignore it because they also had shortness of breath, long after their reaction to someone's perfume has worn off, they're going to be pissed to have to pay a second copay to get their gout diagnosis.
I am going to bask in “like all great truths“ all day today.
So glad to hear it.
We do not get enough basking opportunities.
More common things happen more commonly. No need to treat everyone like a newborn sepsis work up.
Look at lab values in a range and as a trend not as absolute and how they relate to the diagnosis. A potassium below 4 on a pt with arrhythmia or on insulin therapy is not the same as when dealing with acute trauma. Know the drugs and their action on organ systems and stay ahead of them.
Vital signs reflect what’s going on in the pt’s life and not necessarily pathological. A pt in pain with elevated BP doesn’t need nifedipine sublingual ( JUST KIDDING ! )
Elixir of time is a great drug.
Think radiation exposure before ordering x-ray tests. If an ultrasound will suffice, why a CT ? CT can cause 15-100 times the exposure vs an abdominal film, even with modern dose reduction techniques. U/S is zero. Less need for pre-approval ….
You are in training. Ask for guidance when in doubt.
The medical record is a legal document, treat it as such. Re-read before closing it to avoid problems later. The original version is available despite there being an amended one.
As a doctor I worked with years ago, “Will this change our plan of care.”
I’d add, if you try to do everything you end up doing nothing. The patient who comes in with back pain and whose mom just passed does not need to be lectured on cancer screening, or worse, blindly given a colonoscopy referral. Or even worse discussed options on where to get Tdap so tetanus is Uptodate.
As a long time “preceptor “ of FP residents this piece rings so true. “Baseline “ bloodwork, knee jerk consultations, unhelpful testing, and “do something “ are a large part of the guidance I provide. This piece should be required reading for all docs who do this work.