Robert Centor MD MACP 🇮🇱 Profile picture
Apr 18, 2020 14 tweets 5 min read Read on X
1/
Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal

CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
2/

CAP

Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
3/

Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
4/

How often do we mistakenly interpret the patient's language usage to fit our own? We spent (and I am guilty here) too much time on the possibility of platypnea this week without asking key questions to confirm that complaint. Then we never documented orthodeoxia!
5/

Many overlooked the patient stating that the shoulder pain had no relationship to movement - and that was a big clue.

Another patient had a feeling of impending doom - yet her exam and labs gave no suggestion of doom. And yet we were slow to consider a "non-organic dx"
6/

Matt on Friday exemplified naturalistic decision making. We discussed this in a JGIM article:
7/

Schleifer, J. William, Robert M. Centor, Gustavo R. Heudebert, Carlos A. Estrada, and Jason L. Morris. “NSTEMI or not: a 59-year-old man with chest pain and troponin elevation.” Journal of general internal medicine 28, no. 4 (2013): 583-590.
8/
Dr. Gary Klein, leader in the field of naturalist decision making, proposed recognition-primed decision making. He focuses on the steps to expertise, rather than the causes of errors. This discussion highlights Klein’s greatest contribution – the pre-mortem examination.
9/
“In this approach, our expert imagines choosing a given dx with its resultant rx. The expert then ... simulates the potential consequences. If the expert still has doubts because the mental simulation raises cautions, he will seek more information before committing to the dx.”
10/

Matt felt uncomfortable with a headache patient. His problem representation implicitly included some "can't miss diagnoses". Therefore, he referred the pt from urgent care to the ED -> resulting in an efficient, timely evaluation.
11/
We have had several presentations that involved international travel. The travel has been the clue. But travel within the US is important, especially when fungal diseases are in our differential.
12/

Finally I reflect on why #VMR is so attractive and useful to me after > 40 years as an attending physician. I am always trying to learn more about medicine. Each session has some AHA moments - and those moments will likely help me make a diagnosis sometime in the future.
13/
Internal medicine is & has been my vocation and avocation. I love the #VMR community - people with the same love of clinical reasoning. We are all on rising curve of knowledge. This curve likely has no flattening. And we all love learning. We are the best kind of nerds.
14/

These sessions are the intellectual highlight of each day.

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More from @medrants

Sep 15, 2022
1/ #UncleBob - on giving formative feedback on rounds. First, make it clear in your expectations discussion (day 1) that you will critique many things and label them as feedback. #MedEd @CPSolvers @uabimres
2/ Especially with new presentations, stop after the HPI and both praise the story and provide suggestions on making the presentation better. Emphasize the role of storytelling as separate from having taken a good history.
3/ Understand that when you ask questions - some are hard and some are easy. When a learner answers a hard question well - praise them and note that you are giving positive feedback.
Read 7 tweets
Apr 19, 2022
1/Time for a #UncleBob screed. The question Andrew raises is a very interesting one. First I must provide my understanding of the purpose of teaching ward attending physicians.
I divide this into providing excellent patient care & helping learners grow.
2/ Providing high quality care is a given. Excellent ward attendings evolve with clinical practice (consider the 10,000 hour "rule"). But I would argue that both outpatient clinical practice and inpatient practice are beneficial.
3/ And I believe I learn more in a month of ward attending than if I did a month of solo patient care. Patient care requires attention to detail, diagnostic excellence, management efficiency and proper use of tests and consultants.
Read 10 tweets
Mar 7, 2022
1/ #UncleBob recently presented a patient who had a hyperkalemia, normal gap acidosis (type 4 RTA) to @DxRxEdu & @rabihmgeha

But why does hyperkalemia cause a normal gap acidosis?

@tony_breu
2/ Some basic physiology - we metabolize around 1 mEq of H+ daily from our diet. We buffer that acid using titratable (phosphate) and non-titratable (NH4+) acids.
The phosphate pathway does not vary much, but our kidneys can normally control the ammonium pathway
3/ Where does the ammonia come from? Glutamine -> glutamate under the enzyme glutaminase produces NH3

Here is the interesting part. Increased K inhibits this enzyme, thus we produce insufficient NH3 to buffer our dietary intake.
Read 5 tweets
Mar 7, 2022
#UncleBob posted this link yesterday. Here are a few thoughts on the article. “I don’t know what’s the matter with people: they don’t learn by understanding; they learn by some other way—by rote or something. Their knowledge is so fragile!”

— Richard Feynman

Reminds me of M1&2
"The difference between reasoning by first principles and reasoning by analogy is like the difference between being a chef and being a cook. If the cook lost the recipe, he’d be screwed."

This is so relevant to those who grow and those who stagnate.
"Some of us are naturally skeptical of what we’re told. Maybe it doesn’t match up to our experiences. Maybe it’s something that used to be true but isn’t true anymore. And maybe we just think very differently about something." - The best diagnosticians always question previous dx
Read 5 tweets
Feb 16, 2022
1/ Here is the story - hopefully instructive. Patient (ESRD w/ dialysis) admitted 3 weeks previously for dyspnea. Portable CXR shows small pleural effusion & some haziness - pneumonia or atelectasis. No fever, no increased WBC, no productive cough. Discussed now w/ radiology
2/ Radiologist teaches our team - pneumonia is a CLINICAL DIAGNOSIS - cannot make the diagnosis by CXR/CT scan.

Patient discharged - readmitted for more dyspnea - now with moderate pericardial effusion and large left pleural effusion. Receive furosemide & then thoracentesis
3/
fluid LDH - 136
fluid TP. - 3.8
serum LDH - 212
serum TP - 5.6

Fluid very clear - pH 7.43 - no WBCs

Light's criteria - exudative effusion

All appropriate pleural fluid studies negative
Read 6 tweets
Jan 30, 2022
1/ #UncleBob hopes those on the fence about vaccines will understand this
Weekly COVID-19 death rate via CDC:

Unvaccinated: 9.7 deaths per 100k
Fully vaccinated: 0.7 deaths per 100k
Boosted: 0.1 deaths per 100k
2/ Yes you can get omicron even if you are boosted

BUT

You are less likely to get infected
If you get infected you are much less likely to need hospitalization
If you need hospitalization, you are much less likely to need ICU care, and MUCH less likely to die
3/ Would you turn down medical care if you got sick?

I assume no - almost everyone comes to the hospital and ask for everything

Then why would you not accept a free prevention tool?
Read 5 tweets

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