Saturday, March 22, 2014

Antifragile but Exposed: A Framework for Understanding Disease that Can Improve Diagnostic Decision Making

Ruination IPA by Stone
It is said that the history reveals the diagnosis 90% of the time, but it is not stated why this is so.  Herein I will explain the logic behind this aphorism.

I used to tell residents that most of the time, the diagnosis is something common, or something related to something we already know the patient has.  In addition, when teaching history taking, I told the medical students to view history taking as an exercise in determining what the patient is exposed to in his or her environment, for these exposures weigh on the probabilities of potential diagnoses.  These principles explain the basis of the history aphorism.

Nassem Nicholas Taleb was right in his book Antifragile - evolution has made our species beyond robust - antifragile, a term which he coined.  We resist disease, we repair injury, we get stronger when exposed to stress (the antifragile principle).  But there are ailments that humans suffer for which evolution has not worked out a defense or a solution, or those which result because evolution is helping the same organisms which attack us become antifragile just as it selects us for antifragility.  This is why infectious maladies are at the top of the list for adult (and I suspect pediatric) internal medicine admissions.  Pneumonia, UTI, URI, etc.

Friday, March 21, 2014

The Hits are Recorded, the Misses are Not: How the Culture of Medicine and the Third Party Payer System Foment Waste and Inefficiency

It doesn't make sense, but that's how we do it.  Usually, if you want to judge the calibration of a decision maker, you tally hits and misses both, not just the hits.  If you fail to record misses, a high hit rate might just signify a lot of swings.  But in medicine, we are taught to ignore misses.  It's only hits that count.  This doesn't make sense because it encourages overtesting and waste.  If surgeons practiced this way, all heck would break loose, everybody would be cut open and organs wantonly plucked from them.

There is a physician at a Midwestern institution who is known to come on service and order an echo bubble study on several (all?) patients the first day he is on service.  He has doubtless impressed a generation of medical students when the occasional PFO (patent foramen ovale) is found and he gets to wax prolific about shunts and other mechanisms of hypoxemia for a few minutes as they listen with fawning and rapt attention.  What they do not know is that he finds PFOs about 10% of the time he orders his echos, and this is just above the rate of PFOs in the general population.  He's basically finding PFOs at random.

Wednesday, March 12, 2014

No MOC for Me: Why I'm Not Signing Up For Maintenance of Certification

By the end of this month, holders of ABIM (American Board of Internal Medicine) and ABMS (American Board of Medical Specialties) board certifications are supposed to sign up for "Maintenance of Certification" a requirement that costs a bunch of fees and poses a bunch of busywork problems for physicians.  In general all I have heard in terms of reactions from colleagues are frustrated groans and begrudging acquiescence.  But I refuse to sign up for MOC.  Here are the reasons why.

Firstly, I am not required, for my employment, to have a board certification.  Nor am I for any other reason.  The only institution which can "force" you to have board certification is your employer or a hospital credentialing committee.  So, if somebody's gonna be the guinea pig, it may as well be me.