James Nelson MD

Anomalies are the key to a tough diagnosis. This is why an open history style is better than closed. ("tell me about your symptoms" elicits the foot numbness, whereas "was your chest pain sharp vs dull, did you have nausea, did you have shortness of breath misses that)...anomalies allow you to find out that this is aortic dissection.

Physical exam vs tests: is there a wound infection post-op? CT says no, and my colleague consults me. I probe the wound with a Q tip and a lake of purulence flows out. The tests are constantly wrong and are only thought to be better than they are due to lack of an alternative reference standard. @usamasyedMD

There is a difference between the hypothesis-driven exam and the mindless ritual applied without critical thought. Are you opposing #2 only or also #1? All tests explore pathology. Some ask "what would this pathology do if I shot x-rays through it?" Others ask "what would happen to the water molecules if I applied a strong magnet," others say "lets bounce sound waves on it and see how well they return." The hypothesis-driven exam says "I wonder what this sounds like, feels like, how it reacts if I push here vs there, if I tap on it" etc. An expert physician doing a physical exam should be doing it while they continue to ask history questions and they get a much better understanding.

This triggered a fair number of doctors on my feed. Some people are reading this as me saying "it's great and I hate physical exams". I'm stating here what is ACTUALLY the lived reality on the ground in U.S. healthcare. WHY the physical exam has been relegated to this new performative role mainly for billing is due to: - More availability of diagnostics: fair, that's evolution. We don't NEED to rely on the reverberations felt by the side of our hand at any given moment during an exam and operator error etc. which is progress). Doctors who are triggered here seem to be only imagining themselves and how good they feel like THEY are at physical exams. But what if your family member was getting examined by the worst doctor you trained with during residency... do you STILL trust that physical exam? Or would you rather they send a diagnostic and get more objective data? - Malpractice risk: If a patient gives you a history that is classic for X condition, but your physical exam during that snapshot does not support X, and you refuse to treat empirically or order confirmatory diagnostics, your chances of getting sued are much higher by 'taking a stand' based on your physical exam. And in a non-zero set of cases, you'll be surprised yourself when diagnostics throw up surprising results that didn't fit your exam. In the majority of cases, it will be 'wasted' treatment/spend on diagnostics, which no patient cares about on an 'N of Me' basis. - Patient expectations: if a patient has convinced themselves they have a specific condition, and you reject it based on your physical exam alone and don't order follow-up tests, they're likely to slaughter you in online reviews. They're not in a position to understand the screening capabilities of physical examinations, and they'll assume you 'didn't take them seriously'. Doctors learn this the hard way earlier on in their careers, and they decide this isn't a fight worth fighting. *Also to be clear, I don't consider just LOOKING at a patient to be the same as a 'physical exam'. Visual cues give a lot of information even now and dramatically change management/ severity triaging. I'm talking about hands-on physical exams.

There are skills in medicine that are less susceptible to hypothesis-driven research, and therefore not published in journals. In medicine, making things not happen is one of those skills. 5/

It is even more complicated when you have the judgment to withhold a treatment that could bring both harm and benefit. There is less blame for action than inaction (eg compartment syndrome if concern for false positive, asymmetric risk for action vs inaction). 4/

When I first started working in EM, I noticed there was one physician who always had easy shifts and patients just did not get complications (as often). We thought he was lucky. It was only later that I understood that in medicine, skill means you make things not happen 1/

Although paranoia/psychosis is an obvious example, all patient encounters in the ED involve getting in their head and looking at how we can help from within the patient's own way of seeing it. This is patient-centeredness. It is the foundation of success in emergency medicine 3/3

As doctors, our job is to help. Arguing against the FBI theory is irrelevant. So we say "that sounds like a lot of stress, let me give you something that will balance your mind and we can circle back and go from there." 2/3

A patient who presents to the ED saying "the FBI is after me" has some level of insight into their psychosis, because if the FBI is really in pursuit, the ED offers no refuge. 1/3

How to reduce arguments in the hospital: 1) see the patient at the bedside first. 2) reframe the argument, ie "let's focus on what's best for the patient." Maybe this does not solve it 100% of the time but skipping one of these 2 is so often the reason it went downhill.

@RogerSeheult @TiredActor She is satirizing those who dont really care about the patient getting better. When a doctor cares about the patient they try to help the patient get better through both means. They can tell the difference pretty quickly. From your videos its pretty obvious you care a lot!

So as a physician please help me out here. I get that you are frustrated with a chronic disease. Understood. What I need help on is the reconciliation between those that criticize us for NOT bring up the importance of basic things like diet, sleep, and exercise and those here that mock those very things during this visit. Which is it?

Every. Time.

5% of all ChatGPT queries are healthcare related. This illustrates how much patients seek to understand. As physicians, when we complete the ED visit, we should make an attempt to connect our insights to their life (eg, "cutting down on salt will help this more than lasix..."

Rib fracture essential teaching: don't sneeze for 6 weeks, which can be achieved by confusing the sneeze reflex. When feeling a sneeze coming on, rub the nose vigorously. This actually works very well.

The claim is exaggerated. The ER can feel pretty inefficient and people are still paying with their time. I personally don’t believe doctors should be judging the necessity of a visit and instead their focus should be on addressing the patient’s concerns. The less sick they are, the easier it is to do. If you are in it to help people, then the more dysfunctional the rest of the system is, the more meaningful it feels to help people at least have one spot where they know they can get care.

I have a buddy that’s an ER doctor and he claims with 100% certainty that if Medicaid patients only had to pay a $10 co-pay per visit that 80-90% of ER visits would stop overnight. Anybody else in the medical field want to comment?

Creativity is one of the most important of the physician's virtues. If you care about your patients, you will apply ingenuity to their case. In the outlier cases and time-dependent emergencies, it can be the most important thing we do.

How can a 99% accurate medical test give you a 9% chance of having the disease if it comes back positive? 🤔 If you are in medicine this is the SINGLE most important diagnostic testing concept to know. Welcome to the difference between specificity and positive predictive value. Sensitivity & specificity are fixed test properties. These do not factor how common a disease is (prevalence) Positive Predictive Value (probability a positive test reflects having a disease) factors in prevalence and is actually more important to clinicians than sens/spec. It is harder to figure out though because we need to have a gestault for how prevalent a disease is for the EXACT patient we are seeing. If you have very low prevalence, even with a great test, most positives are false positives. This is why screening low-risk patients can result in many false positives and harm To master this, just play with the calculator yourself and you will see!!!!👇

Really important point here. Fear is underrecognized, by doctors, yes. Often also by patients. By recognizing it, we help them move forward