国家冠军的经验教训

3

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所有医生都有失败。The best physicians learn from those failures.他们成为更好的医生,并致力于持续改进。

Everyone who knows me well knows that I have had a 52 year obsession with UVa basketball.虽然我喜欢所有的运动队,篮球是我的真爱。Better wordsmiths than me would have a difficult time explaining my joy in Monday night's championship game.你可以想象我在去年第一轮失利后的黑暗处境。

So what does this have to do with medicine.也许什么都没有,但是我们可以从文学中吸取重要的教训,music and sports.In this case I will likely stretch the lessons,但在我赛后的兴奋中,please indulge me.

Lesson #1 – do not let a failure define you,而是让它激励你。Focusing on diagnostic errors (which we all make),从这些错误中吸取教训。Every diagnostic error happens for a reason,探究原因并拥有它们。也许你(像弗吉尼亚)需要修改一些程序。

第2课-注意细节。弗吉尼亚的教练,东尼班尼顿强调在不考虑未来财产的情况下玩每一种财产。呆在当下,分析你在哪里,不管你昨天在想什么。Has the patient gone down the path expected?Does the diagnosis still make sense.

第3课-不要害怕改变你的方法。从你的错误中吸取教训,不要重蹈覆辙。

第4课-拥抱谦卑.我们从来没有我们想要的那么好,也不像我们担心的那么糟糕。必威体育了解你是谁,努力改善自己,即使你真的很好。We can always improve.我们总能从别人身上学到一些东西。

Lesson #5 – value everyone on the team.护士可以使我们变得更好;职员能使我们变得更好;the cleaning staff helps everyone.作为主治医师,我向居民学习,interns and students.我的第一个目标是帮助每个人提高,同时关注患者和学习者。我们向病人学习。最小化层次结构,然后每个人都受益。

I hope that I have provided some food for thought.I cannot describe my happiness with basketball today.But almost every day I have that same happiness with internal medicine.I continue to make mistakes,但不要害怕他们。We all try to minimize them,但是,当他们发生时,我们必须为了我们自己,更重要的是为了下一个病人,从他们身上学习。

betway 客户端

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Like most internists,I love a good mystery novel,TV show or movie.Mention Sherlock Holmes and internists smile.当博士马克·夏皮罗想补充一下。Gurpreet Dhaliwal for his diagnostic expertise,他给他们的播客讨论贴上了标签-Gurpreet Dhaliwal,The Sherlock Holmes of Medicine

研究虚构的侦探有助于我理解优秀诊断的一些基本原则。必威体育A common trope in detective novels is the misdiagnosis.Someone has been falsely accused or even convicted of a heinous crime.Superficially,证据指向被告,but the fictional detective has an uncomfortable feeling because of something in the case that does not fit.

在BBC系列节目中,SherlockSeason 1 Episode 2,Sherlock states,“You have a solution that you like,但是你选择忽略任何你认为不符合的事情。

It's that uncomfortable feeling you get about a patient's diagnosis.许多年前,我把它描述为阅读关于病人诊断的教科书描述,发现它不适合。当这种情况发生时,病人没有错,rather you are reading on the wrong page.

当这种情况发生时,we need more data,or as Sherlock said in the Adventure of the Copper Beeches,“Data!Data!数据!”他不耐烦地哭了。“没有粘土我做不了砖。

有时数据来自再次询问患者。When stumped go back to the bedside.或者像阿加莎·克里斯蒂为赫拉克利·波洛写的那样,“在我看来,这就是侦探工作的全部,wiping out your false starts and beginning again.Yes,这是非常真实的,that.And it is just what some people will not do.They conceive a certain theory,一切都必须符合这个理论。If one little fact will not fit it,他们把它扔到一边。但总有一些事实不符合这一点。

When the diagnosis does not make sense,重新开始。Michael Connelly's great character Harry Bosch said,“这些年来,我学到了如果你不止一次地问同一个问题,你会得到不同的回答。" And this really happens at the bedside.

这些美妙的,entertaining detectives give us permission to be skeptical of accusing a particular disease as the cause of the patient's illness.我们欠病人一个冷静的,对他们诊断的真实性的顽固态度。We have great role models from whom we can all learn.

And remember the wisdom of Dashiell Hammett in the Thin Man,“The problem with putting two and two together is that sometimes you get four,and sometimes you get twenty-two.

Confusion after gastric bypass with Roux-en-Y

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在最近的案例会议上,we discussed a woman who had had a gastric bypass 20 years previously,现在却很困惑。提醒您胃旁路的细节:

First,a small stomach pouch,approximately one ounce or 30 milliliters in volume,is created by dividing the top of the stomach from the rest of the stomach.下一步,小肠的第一部分被分割,分离的小肠的底端被提起并连接到新创建的胃袋。The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

I posed this question on twitter,but unfortunately did not give enough specification of the problem.Restated,进展混乱的患者在手术后数年(减肥非常成功)没有明显感染。

我们的主要区别包括高氨化性脑病,thiamine deficiency,B12 deficiency and d-Lactic acidosis.

We excluded d-Lactic acidosis become the symptoms were not episodic and the electrolyte panel did not have a moderately increased anion gap (usually around 18).B12水平正常,excluding that possibility.

患者同时患有高氨血症和硫胺素缺乏症。She also had several vitamin B deficiencies and low levels of copper,zinc and selenium.

适当更换后,her confusion eventually improved.

高氨血症的问题非常危险。This paragraph from a近期文章explains it well.

Patients presenting with hyperammonemic encephalopathy after Roux-en-Y gastric bypass surgery presented with overlapping clinical and laboratory findings.Common features included: (1) weight loss following successful Roux-en-Y gastric bypass for obesity;(2) hyperammonemic encephalopathy accompanied by elevated plasma glutamine levels;(3)无肝硬化;(四)低蛋白血症;血浆锌含量低。死亡率为50%。Ninety-five percent of patients were women.

很可能缺锌是这里的罪魁祸首。对鸟氨酸转碳淀粉酶循环的研究表明,锌是一个重要的共因子。像许多成功的搭桥手术患者一样,患者没有服用含有微量金属的补充维生素。有几家公司生产标有“减肥维生素”的维生素,这些维生素有足够的微量金属补充剂。

在我们的会议上提出的病人在接受包括锌在内的补充剂后最终表现良好。

播客在医学教育中的作用

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显然我很有偏见,举办一个播客现在8个月,and being a guest on two other popular podcasts – The Curbsiders and The Clinical Problem Solvers.Given my obvious COI,here are my thoughts on the contribution that podcasts are making for students,residents and practicing internists.

Two or three years ago some students asked me if there were any good podcasts to listen to while on their medicine clerkship.Soon thereafter,two things happened: The Curbsiders started their podcast and the Annals of Internal Medicine asked me to develop a podcast.我越来越喜欢播客作为长途旅行的伴奏。当路边的人让我出现在episode #16在2016年10月的新播客中,我抓住这个机会,开始和医学播客谈恋爱。

Now when I make rounds for 1/2 months or full months,我经常向学习者推荐播客。现在我们已经发行了16集Annals on Call,I frequently get comments from colleagues and learners about individual episodes.本周在我们中午的会议上对医院医学进行了更新,podcast episodes were quoted.Earlier this year the CMRs asked me to give Grand Rounds on social media.The response from house-staff and faculty was outstanding.

Why so much excitement about podcasts?我认为这是我们学习的经典方式。讲故事可能是最古老的教育形式。We learn best from stories.This concept holds particular in medical education.Patients are our best teachers.The best is taking the history ourselves and then following the process of diagnosis and teaching.其次,最好是向别人学习,告诉我们一个关于病人的引人入胜的故事。

我认为我们不能高估临床报道的价值来扩大我们的医疗诊断和治疗能力。As a resident,I loved and tried to never miss Morning Report.I love hearing cases presented at a conference and discussed in depth.That knowledge sticks so much better than reading an article,unless the article helps me 必威体育understand my patient.

除了上面的2个播客外,我特别喜欢临床问题解决者,因为他们每周都会提供一个精选的早报案例来解决。他们专注于评估问题的思维过程和模式(晕厥,嗜酸性粒细胞增多症胸痛,etc.).

Other IM podcasts that I frequent include Core IM and Bedside Rounds.I get different things from each podcast,but most of all I get continued learning.Even at age 70,我想继续学习更多,这样我才能更好地教和照顾病人。

Podcasts increase learning and (IMHO) the joy of medicine.作为内科医生,we love solving our patients' puzzles.We all want to be Sherlock Holmes.这让我们更亲近了。And I love that our students and residents are enthusiastic devourers of this teaching.

The problem of admission diagnoses – a guest post

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I received this response to a recent post.It is so good that I wanted to share it – so with Dr.Thomas Nielson's permission I have.他指出,急于给病人贴上诊断标签的做法会带来意想不到的重大负面后果。He says it so well that I encourage your reading and comments.

Thank you for this post.这是一个经常发生的问题,我相信,目前的招生制度是问题的一个重要部分。

我们被要求诊断急诊科的人员,因为我们需要“入院诊断”,以便确保我们符合“入院标准”。医院管理部门要求这样做的人从未亲自照顾过病人,and they have no idea what they are talking about.

There is a disconnect between administrative types and doctors,and I do not know how this can be solved in our current system.

例:患者出现AMS,发现ED患者有大量酸碱紊乱。What is the diagnosis?I have no idea!I need to admit the patient to the hospital and run a bunch of tests before I can tell you what the underlying problem is.是乙二醇中毒吗?是他们的肾衰竭吗?我不知道。

当前的系统将推车放在马之前,要求进行入院诊断。What happens is some random diagnosis is given to the patient so that we can get them into the hospital.不幸的是,因为系统要求我们对患者进行“优质”护理,这个诊断使一个过程就位。Now the patient is run through a bunch of tests relating to the admission diagnosis which may or may not be the actual problem going on with the patient.And at the end the patient is sent home,dazed and confused,他们对世贸没有一个明确的了解。必威体育

你以为我在开玩笑?这个例子怎么样:呼吸急促的病人,急诊室的放射科医生说肺血管充血。BNP为300。Now the patient is admitted with "congestive heart failure".Do we know it is CHF?NO!But now,因为CHF是一种诊断,BeanCounters相信他们可以单独通过协议进行治疗,the patient is set upon a course in which all of the "quality" measures must be met to make sure that we get paid.The patient does not know what is going on,但突然间他们开始吃低盐饮食,服用血管紧张素转换酶抑制剂,等等。他们(希望)会得到一个超声心动图,然后……如果超声正常会发生什么?SYSTEM FAILURE

To get back to your post,it is often the system that is running away with the patient when we have a sense that the diagnosis is wrong.研究反复表明,在这个过程的早期,把诊断钉在病人身上,这是所要求的系统,导致医生在治疗过程和判断上存在显著偏差。

在这个国家,我们需要的是医生们恢复他们在医疗体系中的合法地位。所有的质量指标都需要直接发布。

我们该怎么做?I am afraid that we are going to have to revert to doctor-run hospitals,全部现金。Let patients deal with their own insurance companies.

忽视直觉的危险

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最近,我们有一个病人因诊断不符合他的问题表现而入院。The diagnosis was a convenient one,而且容易治疗。他最初对治疗有反应,我们把他出院了。The diagnosis assumption nagged at me,但我并没有推动我的思想所需要的测试。

一周后他回来了(可怕的再次入院)。有同样的症状。住院医师扩大了对同一诊断的治疗。

第二天早上见到病人时,我们甚至比第一次入院时更不舒服。

As often happens,这是一个社区获得性肺炎的故事,而不是上限。我们安排了一次CT扫描,以澄清异常x光。我们和放射科医生一起检查了CXR和CT。His symptoms never fit CAP.他的CxR可能是Cap。只有CT扫描显示我们的方向是正确的。

I preach expanding the diagnostic evaluation when the problem representation and the illness script do no match.Yet,doing so is often difficult.我们病人的诊断推迟了一周,整个星期都不舒服。

所以我在挑战自己。I "knew" that we did not have the right diagnosis,but "I did not pull the trigger".I am not unusual.我怀疑我们都有这个错误。

第二次我毫不犹豫。How do I convince myself to honor my instincts in such patients?

我怀疑你们都经历过类似的情况。这个故事(我为病人保密保留了一些细节)对其他人来说很常见。

I hope to do better the next time.Part of not doing better is refusing to rationalize what happened,而是从经验中学习。The patient improved dramatically when we treated the right process.

我的推特收藏

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You can probably tell that I tweet much more than I write blog posts these days.我已经开始做tweetorials——链接的tweets集合,讲述一个故事。大多数tweetorials代表教学,或者更确切地说是在线粉笔演讲。

They are now being collected (along with other tweetorials that I particularly like and want to use.Here is the link:Medrants Tweetorials

如果你不在twitter上关注我或者不使用twitter,您仍然可以使用此链接阅读这些教学课程。

The man in 558

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来接学生,服务第一天的客房服务员和病人总是让我兴奋。这个星期一也不例外。我在等什么?How many patients would I need to see?What lessons could I impart?

When I arrived we had 11 patients,2个新的和9个已经到达。Going through the list,while routine,总是激发提问和教学机会。Sometimes the team had questions for me.Sometimes they had a mischievous sense of putting me on the spot.我一直喜欢这种相互作用。

When we got to the man in 558,他们讲述了一个关于一个患有晚期癌症的愤怒男人的悲惨故事。He had accepted this fate,but was angry that we could not control his pain.他拒绝服用阿片类药物,因为便秘疼痛比癌症疼痛更严重。整个团队都在避免见到这个人,除非他们必须这样做,因为他会对他们大喊大叫。当面对愤怒时,移情变得困难。

我们在医院里走来走去,在558年,我从未想到过那个人。我们有各种医学上有趣的问题。我们让病人检查和演示身体检查结果。我们有出院计划。

但不可避免地我们到达了558。我走进房间和他谈话。小组画了一幅准确的图。他叙述了这个问题。He was obviously miserable.I told him that we would discuss a plan and involve palliative care.I explained that they were the experts at treating pain and side effects.

Outside the room I did something I rarely have to do,I had the team discuss constipation management.Usually I let the team figure this out without my interference,but in this situation I needed to 必威体育understand what had been done.当他们背诵他们的英勇尝试时,I wondered how I could help.

I asked the team if they had tried an opiate antagonist.很少使用它,I could not remember the name.所以我们查了一下——甲基纳曲酮。我们订购了它,并向病人解释了情况。我们希望它能奏效。We still called palliative care.

第二天,研究小组报告说,他感觉好多了,新的药物让他们重新开始服用阿片类药物。We go to enter the room,一个女人坐在他的床边弹吉他。他们正在唱一首克里登斯清水复兴的歌。The music therapist is smiling,as is our patient.We learn that he had been a musician – a keyboard player – and that CCR was his favorite group.

The man in 558 became fascinating to everyone.他有很好的故事要讲。他在558年成为音乐家而不是男人。

他还患有晚期疾病,但他已经平静下来了。We were able to make his days better.

Palliative care did a great job.让每一天都变得最好。And that went for the team also.

关于风险预测的思考

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这个星期一晚上,我们的下一个播客开始播放。博士。GustavoHeudebert和我讨论了另一篇关于风险预测的文章。这个话题已经成为电话播客年报上反复出现的一个主题。

为什么风险预测如此重要?2019年,我们在风险预测的基础上做出了许多预防和测试的决策。In addition we also estimate harms and benefits.All these predictive models have advantages and flaws.在决定使用他汀类药物时(另一个即将发生的事件)我们必须估计心血管事件的风险,how much taking a statin will decrease that risk,以及服用他汀类药物的可能性和副作用类型。

These predictions all come from mathematical modelling.数学建模充满了许多危险。可以将相同的建模技术应用于不同的数据库,并开发出显著不同的模型。The episode with Dr.Rod Hayward -提高心血管风险评估–举了一个很好的例子,说明包括不同的数据库,甚至不同的时间段如何改变我们对心血管事件的风险预测。在那一集里,他还解释了时间趋势的问题。心血管风险在过去30多年中有所降低。Thus,our predictions should change.

He also pointed out that we never have data on all the risk factors that one would want in a model.The cardiovascular risk prediction models do not take into consideration family history,肾脏疾病或健康——但我们知道所有这些因素都会改变心血管风险。

同样的问题也存在于利益和危害预测中。The promise of big data assumes that we have complete data.Yet in medicine we never have complete data.

这些预测模型可以帮助我们做出临床决策。We should always use them carefully and thoughtfully.必威体育了解到这些数字是具有置信区间的估计值可以帮助我们。他们可以帮助我们与患者就风险和益处展开对话。数字不是魔法。We cannot enter them into a computer program to make clinical decisions.采用算法决策很快就会变得危险。

Many decisions occur in a "grey zone".我们应该考虑到那个病人,他或她的顾虑,以及他们的整体医疗状况。Such decisions are complex and 必威体育understanding these issues makes one wonder about many guidelines and performance measures.我们应该永远记住门肯的话,"there is always a well-known solution to every human problem—neat,貌似有理的,and wrong".

Reflections on my social media Grand Rounds

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Over the past 2 days,参加完大回合比赛后,I did what I always do after giving a talk.I replayed the process in my head,and tried to 必威体育understand what I had done well and not as well.But this time,given the new topic,我的思考使我对社交媒体的使用以及与博士一起进行的“大实验”的重要性有了一些启发。Matt Watto to discuss podcasting.

My first 必威体育understanding was that blogging has mostly served me.它给了我一个成为更好作家的平台。But more important it has allowed me to put my ideas down on paper.这个过程让我可以测试出想法,concepts,以及使我的思想更清晰的方法。它允许我对这些想法进行测试。这些想法并不都奏效,but many do.Many become refined as I try to express my thinking.

另一方面,Facebook只是(对我而言)保持联系的一种方法。我确实了解以前的学生和居民的情况。But this is my least important social media presence.

Twitter has become a major part of my personal continuing education.因为我的推特习惯,我已经设定了每天至少发一条重要医疗理念的标准。最常指的是文学或播客中的一篇文章。

Podcasting is rapidly becoming a major method in medical education.我有一位同事采用播客作为获得CME和MOC学分的主要方法。She has young children,works part-time,而且很难去开会和上课。她发现播客很方便,对她的工作和生活平衡有重要贡献。

许多居民在健身时也会收听播客,或者上下班的时候。They love medicine,and enjoy learning during those times.

These ideas seem more clear than prior to developing and giving the Grand Rounds,but none of these are as important as my "big reveal".

与马特的谈话显然是我们大回合的亮点(持续了大约20-25分钟)。Both colleagues and residents told me how much they enjoyed the conversation.Both The Curbsiders and Annals On Call are conversations.

当我听播客时,我发现最有趣的是那些涉及对话的。So,as I was pondering this phenomenon,我想知道这是否应该是更大回合的一部分。

在我们的项目中,住院医师将早报和临床问题解决会议作为他们最好的学习经验。These are conversations.

Having 2 or more people discuss a topic,澄清想法并提出后续问题,helps me absorb a topic better.The classic lecture is usually boring as hell.我做过很多大的讲座。经过多年的磨练,我的技能得到了很好的评价。No matter how well I do,我非常喜欢交谈,discuss patients and try to apply and expand knowledge to helping patients.

I think this is a personal epiphany.我们需要弄清楚如何把对话融入我们的教学专业。我希望这对读者有意义。Typing this is helping me play with these thoughts.

  • 技术官僚
  • 推特