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Robert Centor MD MACP medrants@med-mastodon.com Profile picture
@medrants
May 16, 2020 • 7 tweets • 4 min read • Read on X
1/ #UncleBob takes #5goodminutes to wax philosophically
I love Saturdays … but no #VMR today. During the pandemic #VMR has made a wonderful contribution to my sense of purpose & community. @CPSolvers @DxRxEdu @rabihmgeha @Sharminzi @ArsalanMedEd @haematognomist
2/ As many know, I am semi-retired - only work 3/8 at the VA as a ward attending. My wonderful colleagues have decided that because of my age (fortunately my only risk factor) that they will keep me off the wards for now.
3/ Those who know me will understand that my career highlights all involve ward attending. I am fortunate to have good health and the resources to stay away from the hospital without any major difficulty.
4/ I exercise every day, spend too much time on twitter, but I would not be as positive as I am without #VMR These sessions exercise my brain, allow me to pass on > 40 years of internal medicine learning. The wonderful learners & educators in the chat have all become important.
5/ Each day after I log in, I check the attendee list, seeing old favorites and new names. Each day I learn more internal medicine - at no time in your career should you stop striving to learn more.
6/ I might be physically distancing, but thanks to my #VMR pals, I am not socially distant. There is nothing more important to this old internist than learning and passing on things learnt. Only then are we prepared to best help our patients. Thanks for keeping me sharp.
7/ I can't wait to get back on the wards and help both patients and learners, but in the meantime thanks to everyone who attends #VMR for making me feel great!

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More from @medrants

Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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
Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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
Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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
Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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
Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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
Robert Centor MD MACP medrants@med-mastodon.com Profile picture
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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