ACP Internist Blog


Monday, May 17, 2021

Is my new doctor qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn't this make sense? Consider these examples.

A clarinetist applies for a position in a symphony orchestra. While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship. Would he ever be hired without playing a note?

A college student wants to join the swim team. The applicant can expect to show off her speed and technique as she cuts across the pool. Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper. The interviewing editor will surely review the applicant's prior work product to gauge his competence and suitability for the new position. Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator. Would such a hire ever occur without determining if the applicant has the requisite language skills?

So how does the medical profession hire on new medical professionals? I should certainly know this since I've been in the trade for 3 decades and have had enough job interviews to know how the process works. I'll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn's disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked? None of the above. For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview. Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue. The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense. Shouldn't the applicant at the very least be asked to review case histories of assorted patients and to comment? It seems it's a lot tougher to get a job as a clarinetist than as a gastroenterologist. Does this put your mind at ease?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Tuesday, April 20, 2021

Some thoughts on diagnostic reasoning

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 consultants and often biopsies.

The second version includes the majority of patients – a straightforward diagnosis. We need not spend much time on diagnosis unless the respond to treatment raises warnings that we might have the wrong diagnosis.

The third version involves patients whose presentation involves some subtleties. These are the patients who too often do not stimulate diagnostic curiosity. Yet, when we pay attention to the subtle clues, we often reopen the diagnostic process. The most fulfilling diagnoses that I and my teams have made occur in this latter category.

This fits an Osler quote, “The value of experience is not in seeing much, but in seeing wisely.” The astute diagnostician observes a lab, or physical finding, or imaging finding that does not fit the assumed diagnosis, and has courage to question that diagnosis. Sometimes the trigger finding does not yield a new diagnosis, but we still have the responsibility to wonder, think, and pursue another diagnostic possibility.

We have presented two such cases in our @unremarkablelab YouTube videos: https://t.co/EWwezNBhiE and – https://www.youtube.com/channel/UCVQ3Na5zXk5lpdUfPKhZ_Ew

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Monday, March 29, 2021

Imagining the post-pandemic workplace

Millions of Americans are working remotely during the pandemic. Many of them would have never believed that they could perform their jobs away from the office. I'm one of them. But we all now acknowledge that the basic structure and function of the workplace has been forever altered. This transformation was inevitable, but the pandemic was a potent catalyst to bring it about at, shall I say, “Warp Speed”? Did we really believe that in a world with remote robotic surgery, driverless cars, personalized genetic medicine, exploration of Mars, Alexa and the explosion of artificial intelligence, that we would continue to commute to brick-and-mortar offices each day? It was only a matter of time before the physical workplace would be recalibrated.

The disruption has been monumental and to a great extent irrevocable. While I do believe that there will be some backward adjustment after the pandemic has largely resolved, I do not expect a return to the status quo ante. Do you think that DoorDash will be out of business then?

And as occurs after every disruption and innovation, there will be winners and losers. The printing press came about in the 15th century. Good idea? Probably yes, but it may have been a job killer for many.

Many industries are very nervous now. If you have earned your fortune up to now in commercial real estate, you may not welcome the prospect that your high-priced office space will no longer be in high demand. Indeed, huge companies are leaving New York City in search of more economical alternatives. Will stage theaters and cinemas ever return to full capacity now that most of us have enjoyed these experiences from home? The hospitality industry has taken a body blow and will do its best to stagger up in the coming year or two. Would you want to be an investor in a sports stadium now? Investors may need to factor in that future pandemics may be lurking.

But it's a good time to be in the vaccine business. If your manufacturing company could adapt to produce personal protective equipment (PPE), you probably could have run three shifts of workers. Remember when we couldn't find sanitizer left on the shelf? Those companies really cleaned up. Grocery and restaurant delivery services can barely keep up with the demand. And with all of us hunkered down in our homes, it has been a good season for Netflix and other streaming services. On-line retail was already doing well pre-pandemic, but they have reached the stratosphere. How do you think Zoom fared this year?

We are all aching to return to normal, but the normal of tomorrow will be quite different from the normal of yesterday. And just when we start to get used to the new normal, guess what will happen?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, March 8, 2021

Should we pay people to get vaccinated for COVID-19?

I read recently that Kroger, who runs a grocery store chain, has joined with other retailers in paying employees who receive a COVID-19 vaccination. The $100 payment should serve as an incentive for employees to roll up their sleeves.

There is an ongoing debate whether employers can or should mandate COVID-19 vaccinations for their employees. The state of play now is that employers are encouraging, but not requiring vaccines, as mandating vaccines creates legal exposure for employers. For example, if you require that an employee is vaccinated against the worker's wishes, and a complication occurs, is the employer responsible? Can an employee be disciplined or terminated for failure to vaccinate if there are no vaccines available within a reasonable distance? And mandating vaccinations may be complicated when workers are unionized.

The right to refuse treatment is a bedrock medical ethical principle that I support. For example, if I advise an individual with acute appendicitis to proceed with surgery, this patient has a right to decline, assuming that the patient is competent, and I have properly informed the patient of the risks and benefits of the reasonable options.

This right, along with all of our rights, is not absolute. If refusing medical treatment has a public health dimension, then the issue becomes more complex. And the terrain can be murky. If a parent refuses to have his school age child vaccinated against communicable diseases, this right collides against the rights of other children and personnel in the school. Indeed, it is for this very reason that school districts can require students to be vaccinated. If a parent objects, then they are free to home school their youngster.

This is why the failure to wear masks when advised to do so is not just a personal decision. It puts other as risk. I don't object if someone chooses to become inebriated at home. But it's quite different if this individual decides to operate a motor vehicle on city streets.

While no vaccine or medical treatment is 100% safe, and there may be unknown vaccine risks that will emerge later, I recently received the two-shot Moderna series enthusiastically. The only incentive I needed was my belief that I would be much less likely to become infected and to infect others.

If a hundred bucks is a necessary incentive, and a business has the will and resources to expend on this effort, then good for them. We're familiar with similar strategies, such as paying kids to do homework.

Should we also pay people to be honest or to be polite or to stop at red lights or to be on time for appointments or to observe speed limits? What should the per diem reimbursement be for wearing a mask?

In other words, should we pay folks to do stuff that they should be doing for free?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.