Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

Many times during residency I looked for a table like this online. There weren’t any, so I decided to create one.

Ye’r welcome.

Source: Induru RR, et al. Managing Cancer Pain: Frequently Asked Questions. Cleveland Clinic Journal Of Medicine. 2011;78(7).

This has become the mantra of every medical student, intern, and resident wanting to appear smart on rounds and conferences, of every attending intent on shooting down a team member’s suggestion. Five, ten years ago it might have have signaled genuine interest. Now it means, usually, “I don’t know anything about the subject, but I’m still calling you out on (what I think is) your BS. Here, look at me! I am evidence-based!”

No, nobody has posed me that question in quite a while, and I don’t remember ever asking it in any context¹. But, honestly, except for a few very well-known examples listed in this excellent post, you can find “evidence” in the medical literature to back up any claim. Off-the-cuff conversations during lectures and rounds are not the best place to dissect them, especially when one side has seniority.

Of the three pillars of medicine, research is the most ellusive. Unless you are in an MD/PhD program—-not an option for most Europeans—-you will have other priorities in medical school. And unless your residency program has a built-in research year, the way most surgical residencies do, you will either be way too busy in a university or a large community program to do any research, or have plenty of free time in a lower volume community hospital that doesn’t have many research opportunities.

When I interviewed residents-to-be last year, my first thought on seeing a non-PhD applicant having 18 publications on his or her CV wasn’t “Wow, she is a research machine, we gotta have her”, but rather doubt that anyone could be that productive during medical school. More points subtracted for thinking the interviewers would be so gullible.

I graduated six years ago, far enough not to be able to give advice on how to do research as a medical student. The hows and whys are institution-specific, so anything I wrote would have to be in Serbian anyway. Residencies, though, are similar enough to each other that I do have some words of advice for new residents wanting to do Research! in a community hospital, university-affiliated or not.

• Patient care trumps research. Unless you have already worked as an attending in another country before coming to the US for residency, don’t waltz in to your PDs office on day one asking about research opportunities. Prove yourself on the field first, then six months later, when you’re comfortable managing DVT prophylaxis, septic shock, and what not, start asking questions.

• Get your own idea? Common wisdom says it is better to come up with your own question and start your own projects, since you will be more invested in the outcome. Well, yes, sort of. Unless it is a quick-and-dirty chart review you can do over a two-week vacation—-and even then there are IRB hoops you’d need to jump through to get anything done—-you will get your inexperienced self into the murky world of project management. Many brilliant ideas have died on the field of required signatures, ambiguous data points, and impossible-to-coordinate meetings. Which is why this next advice is important.

• Find good mentors. Surrounding yourself with a few good people is orders of magnitude better than having many good ideas. Research topics come and go, as does our interest in different fields of medicine (yesterday’s apoptosis is today’s epigenetics is tomorrow’s something or other). It is unlikely that the research your started in residency will continue onward into fellowship, but the knowledge, skills, and general wisdom you pick up from your mentors should serve you well into your career. NB: don’t wait for someone to be “assigned” to you—-although that’s what many residency programs will do. Seek out people who match your character and who would be able to give you advice in at least three fields: patient care, research methodology, and research topics. This can be one person, or five. And if you find an awesome mentor who just isn’t doing any research right then, you can always write a review.

• Is it Science! or quality improvement? ACGME is big on Quality! and Patient Safety! this year. Programs take notice. If you can present your interest as a quality improvement project rather than small-s-science, consider doing it. Not only does showing interest in quality improvement look good on a CV, your institution might have special funds for resident QI projects. A dedicated QI mentor is also a good resource, if you want a carreer as a Sith lor—-erm, hospital administrator.

Interest in research goes from I just want something on my CV so I could get a fellowship to When I grow up, I’ll have my own lab, but this applies to most people in most circumstances.

Four years ago today was my first day as an intern at Sinai. Yesterday was my last on Sinai’s payroll. I will miss it.

Won’t miss the fake flash mobs of Lifebridge Health, though.

The new intern class starts in less than a month. It’s easy enough to find advice on how to be well-organized, efficient, and likable. Here are some more tech-oriented tips I wish I knew back when I started.

Take photos and videos, with permission

Get an iPhone. Turn off Photo stream, or download a camera app that doesn’t automatically upload to it, like VSCOcam. When a physical exam finding is rare, stumps you, or is just cool to see, ask the patient about recording it. If you see an interesting or rare radiography image, save it. But please remove all personally identifiable information.

Useful for: appearing smart on rounds, observing disease course, creating informative slides, posters, and written case reports.

Keep track of things you are interested in

Your EMR will have a way to create custom patient lists. Use it. If you are into hematologic malignancies, eosinophilic esophagitis, MODY—or anything, really—keep track of all your patients who have it. If you don’t yet know what it is, keep a list of all the patients you found interesting and try to find a pattern.

Useful for: getting ideas for research and quality improvement projects, figuring out your career path.

Do not copy forward, copy/paste, or use templates and macros

I started my internship in 2010 so I can’t believe I’ll write this, but—back in the day before EMRs, we wrote our progress notes and H&Ps by hand. This meant reviewing the med list, vital signs, and labs each morning and writing down only the important stuff; completing and recording just those parts of the physical exam that had to be done; and writing a new assessment and plan each day. Well duh, isn’t that what interns should do?—you might naively ask, until your second or third day on the job when a helpful senior resident shows you how to shave minutes—minutes!—off your note-writing time by using some variant of copying forward, templates, or macros.

These tricks are a mental crutch, and a known cause of documentation errors. They might help your handicapped intern self the first few months on the job, but will then prevent you from thinking about what you are doing and writing. A thoughtful daily review of everyone’s medications and labs will turn into a quick glance over a two-page long list of 10-point single-spaced Courier New. Also, your typing speed will never improve if you only document by clicking.

Useful for: being a good, thoughtful doctor.

Marco Arment discovered an old article in The Atlantic pronouncing the triumph of New-Age medicine. It’s been a while since I’ve read it, but the introduction reminded me of what I thought was its biggest fault in reasoning:

… But now many doctors admit that alternative medicine often seems to do a better job of making patients well, and at a much lower cost, than mainstream care—and they’re trying to learn from it.

Alternative medicine does not make patients well. It makes them feel well. The difference is huge.

Here are two graphs from an excellent free-to-access NEJM article that compared four methods of treating asthma: conventional medicine, placebo, sham acupuncture, and doing nothing¹. The first one shows how well the patients in each group felt after 2-4 weeks of treatment.

Ah ha! Conventional medicine was no better than sham (sham!) acupuncture, and both beat placebo inhalers. Alternative medicine wins! Or did conventional medicine lose? At the very least it’s a draw.

Not so fast. The second graphs shows the amount of objective improvement, measured in FEV1—the volume of air you exhale during the first second of breathing out:

If this were the common cold, it wouldn’t have been a big deal. But asthma is not the common cold. People die of it every day, not because they didn’t feel well—though being unable to breathe is doubtlessly uncomfortable—but because their airways were too tight to get any air out of the lungs.

This is why alternative medicine can be dangerous in the wrong hands, with the wrong patient. Improving quality of life is important, but so is curing disease.

• I don’t feel comfortable doing that.—I don’t know what you’re asking me to do (nurse to intern); I’m too lazy to do it (intern to resident); I think it’s a stupid idea and there’s no way you can make me do it (resident to attending); You’re not paying me enough to do this crap (attending to administration).
• It’s a light elective—You don’t need to show up.
• Needs to read more. (on a written evaluation)—I have no idea how much medicine this person knows. I barely know any myself.
• The family is reasonable.—Family members don’t ask too many questions and will agree with anything you say.
• The patient has xyz.—I’ve read in an old discharge summary that the patient has xyz, but have no idea how they established the diagnosis, what stage it is in, or what the hell xyz even is.
• The head is normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Sclearae are nonicteric.—If I were to report the physical exam I actually did it would take five nanoseconds, so take these fillers to make it seem like I’ve put in some effort.
• Thank you for the thorough presentation.—Why did you waste my time with all that useless information?
• That’s an outpatient work-up.—Administration is already breathing down my neck because of this patient’s length of stay and you’re worried about a mild anemia and a positive hemoccult!?
• That’s her new baseline.—Her disease is worse and we don’t know why, so I guess she’s stuck with it.
• Please let me know if you have any more questions.—This is the end of our conversation, so please stop talking. I shall now leave.

…to me, this looks flaky. Yes, Scott Adams (of-Dilbert-fame) is right in saying your best bet for success in life is being pretty good in several skills rather than trying to be the best ever in only one. So, a plan like this:

1. Step one: become a decent entrepreneur
2. Step two: become a decent MD
3. Step three: ???
4. Step four: profit!

might indeed be a good idea. However:

• Medicine implies altruism. Entrepreneurship implies greed.
• Programs want their residents to be 100% dedicated to medicine in general and the program in particular. Can you do that with a small business on the side?
• Physicians in academia, i.e. those who conduct residency interviews, forgo 300k+ salaries so they could dedicate themselves to research and education. Are you sure telling them about your latest money-making scheme is a good idea?
• As a resident, do you look at each patient as an opportunity to help them and learn from them, or to figure out how to build a business around them?

Residency programs exist to train physicians, not CEOs. Residency slots are already in short supply. Would program directors give a position to someone who is more likely to end up not practicing medicine at all?

They let us peek into the sausage factory last week.

Nominally, the lecture was about RVUs¹. An accountant type in a pinstripe suit explained why the government came up with the concept and how more RVUs translate to mo’ money for the hospital. Then he showed us a table. This is how much RVUs an average ophthalmologist makes in an hour. Here is an orthopedic surgeon. See here at the bottom? That’s an internist. This is how much you’re worth to us, scum².

Then there was a chart. This is the last fiscal year. This solid line here are monthly RVUs for an average hospitalist. The dotted line is for a single physician in the practice. See how it’s always above the solid line? That’s good. We love that person.

We had medical students and interns just three months into training listen to this. It was blood-curdling.

Not because the hospital organized the lecture, mind you. It is a very good thing they did it, and it is good for doctors in training to realize as early as possible in what kind of a healtcare system they are expected to work. What is frightening is that there needs to be an entity, let’s call it administration, which views the hospital as a production plant and physicians as line workers who need to maximize outputs, optimize efficiencies and do other newspeak claptrap.

Administration usually lies—appropriately—on the ground floor, far removed from that other sausage factory of actual patient care. It looks at pie charts and histograms and RVU tables and keeps coming up with new and exciting ways to increase production while wondering why those bumbling doctors at the bottom of the list can’t do whatever the top performing docs are doing to keep the hospital in the black.

It’s modern medicine, it’s complex, it’s expensive, it requires that level of organization and detachment—you might be tempted to say. Yes, you could indeed say that, if not for the lonely example of every other country in the developed world which does it differently than the US.

But never mind that. With all the shenanigans the Congress has been up to this week, that end of the equation is unlikely to change. What administrators should do—and I understand the banality of the following advice—is see real physicians interacting with real patients for at least and hour each week. Interns being bombarded by page after page—from critical to comical—while trying to figure out a 15-minute window to eat, get coffee and use the restroom⁴. Residents finishing a 24+ hour ICU shift that started with three codes and ended with a difficult end-of-life care discussion, with central lines placements and intern supervision—but no sleep—sprinkled in between. Attendings getting yelled at while trying to explain to family members why they need to pay for the medications out of pocket or bring their own³.

One hour. Each week. Mandatory. To put things in perspective.