MedEd

“Doctor, Step Away From That Cookbook!”

A middle-aged man develops chest pain at home. Minutes after calling 911, he’s in an ambulance, whizzing through traffic to the nearest emergency room. The paramedics radio ahead, and by the time the patient arrives in the ER, the hospital’s heart attack team has been activated. A stat electrocardiogram shows an ST-elevation myocardial infarction (STEMI), and suddenly It’s Showtime: the patient enters the “chest pain pathway,” automatically triggering a pre-prescribed set of actions: medications, blood tests, oxygen, and more. The cardiologists, nurses and technicians congregate in the cath lab, waiting for the handoff. Nothing is left to chance: the STEMI team even has a special key that allows them to commandeer the elevator. This is life-and-death choreography – George Balanchine meets Dr. John Carter – and it works. In the old days, it might have taken 3 or 4 hours to get a catheter into the patient’s coronary artery. By…

(Not) Saving the Best for Last: Managing One’s Time on Rounds and Sign-Out

A clever little study was published last month in the Archives of Internal Medicine, and it – plus the fact that I’ve just started a stint as ward attending – prompted me to think about the importance of managing a set of tasks in the hospital. In my quarter-century of mentoring residents and faculty, I can’t think of an area in which the gulf between what people should do and what they actually do is larger, nor one in which improving performance yields more tangible rewards. In this blog, I’ll begin by reviewing the Archives study and then consider its lessons for time management, particularly on the wards. In my next post, I’ll describe – just in time for New Year’s resolutions – a little technique I’ve developed that has helped me and others complete tasks that feel overwhelmingly large. In the Archives paper, a research team led by informatician…

In Today’s JAMA: Abraham Verghese and I Discuss the Changing World of Ward Attendings

Senior attendings like to quip that the medical students seem to be getting younger every year. They’re not. But the attendings on the wards of American teaching hospitals actually have gotten younger. At UCSF Medical Center, for example, about 90% of our ward attending-months are now staffed by hospitalists, about half of them physicians in their first six to seven years on faculty. When I was a resident in the mid-1980s, the vast majority of my attendings were senior faculty, mostly subspecialists. Not only has the cast of characters changed, but the nature of being a ward attending has also been transformed by a series of forces, including resident duty-hours regulations, increased supervisory expectations, sicker patients, and electronic health records. Because everyone is so busy and the stakes so high, my sense is that all of those on the wards are a bit uneasy, searching desperately for a new normal.…

Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem

A colleague recently sent me a remarkable video – of Professor Lawrence Weed giving Medical Grand Rounds at Emory University in 1971. It’s fun to watch for many reasons: the packed audience composed mostly of white men in white jackets and narrow ties, the grainy black and white images a nostalgic reminder of Life Before High Def. But the real treat is seeing Weed, then 47 years old, angular and frenetic, a man on a mission. He begins his talk by rifling through a typical medical chart, thick as a phone book. It is filled with garbage, he says disdainfully; “source oriented” rather than “problem oriented.” Weed was promoting his new vision for the medical record – one organized around patients’ clinical problems. In 1964, in an article in the Irish Journal of Medical Sciences (reprised, rather more famously, in the New England Journal in 1968), Weed described his new…

On Becoming Chair of the ABIM: Why the Board Matters More Than Ever

On September 10, 1986, soon after I completed my residency in internal medicine, I “took the Boards” – the certifying examination administered by the American Board of Internal Medicine (ABIM). A few months later, I learned that I passed the exam, and that success, combined with an attestation by my residency program director, rendered me “board certified.” I was granted lifetime certification – my framed certificate implied that I was not only a competent internist at that time, but that I could be counted on to remain one (without any further assessment) until the day I retired. I was all of 28 years old. As the proud owner of ABIM’s lifetime seal of approval, I assumed that my thick envelope was the last contact I would ever have with the Board. I was wrong. Last month, I became chair of the ABIM. The organization has always been well respected in…
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