Category Archives: Internal Medicine

Just Listen

I just got back from a brief trip to Florida. I went down there to celebrate my mother’s 85th birthday. As you might expect, her social circle has shrunk in recent years, but she did get a number of cards and calls from friends and family members. The cards were on display in her kitchen, and a few calls came in while I was there. One in particular pointed out some of the many things wrong with medicine these days. Continue reading Just Listen

Maintenance of Certification or Extortion?

I trained in internal medicine and cardiology at the tail end of the era of lifetime board certification by the American Board of Internal Medicine. In fact, my timing was perfect – I was “boarded” in medicine in 1987, and in cardiovascular disease in 1989, which (I am pretty sure) were, respectively, the last years that the ABIM offered certificates without an expiration date in those disciplines. Continue reading Maintenance of Certification or Extortion?

Practice Guideline Overload

I think I am like many practicing physicians in my “love-hate” relationship with clinical practice guidelines. On the one hand, it is often helpful to look up a set of evidence-based recommendations on a particular clinical issue, and I feel particularly fortunate that the American College of Cardiology and the American Heart Association have collaborated to produce high quality guidelines on a wide-range of subjects relevant to my practice. On the other hand, I am well aware of the shortcomings of practice guidelines, including the limitations of the underlying evidence base, the challenge of synthesizing the available evidence into guidelines, and the often limited applicability of recommendations to clinical practice. Continue reading Practice Guideline Overload

Fear of Malpractice Claims and Defensive Medicine

Few things unite physicians as much as the belief that the current malpractice tort system is seriously broken. The litany of complaints is long and familiar: many suits are without merit; the cost of malpractice defense forces settlements even when the “medicine” was good if the outcome was bad; lawyers take too big a slice of the financial pie; we are all forced to practice defensively to avoid getting sued, thereby driving up the cost of health care. Of all of these, the belief that malpractice fear drives physicians to overtest and overtreat seems nearly universally held. Even so, there has been very little evidence to support it, and efforts to quantify the impact of “defensive medicine” on health care costs have been largely speculative. Continue reading Fear of Malpractice Claims and Defensive Medicine

Violence Prevention

As I suspect is the case with many of you, I find it hard to keep up with all the medical journals that cross my desk. It is especially hard when the latest issue of Car and Driver also crosses my desk, but that is another story. So, generally speaking, the journals pile up. When the pile gets too high, I either skim them “in bulk” or just declare defeat, throw the pile out, and start over again. Despite the general pattern, there is one item in one journal that I read in “real-time”: the “On Being a Doctor” column in the Annals of Internal Medicine. Continue reading Violence Prevention